Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity

BACKGROUND: Stable anatomical reconstruction of the joint surface in ankle fractures is essential to successful recovery. However, the functional outcome of fractures involving the posterior tibial plafond is often poor. We describe the morbidity and functional outcome for plate fixation of the displaced posterior malleolus using a posterolateral approach. MATERIALS AND METHODS: The posterolateral approach was used for osteosynthesis of the posterior malleolus in 45 consecutive patients (median age 54 years) with AO/Muller-classification type 44-A3 (n = 1), 44-B3 (n = 35), 44-C1 (n = 7), and 44-C2 (n = 2) ankle fractures. Thirty-three of the patients suffered complete fracture dislocation. Functional outcome at followup was measured using the modified Weber protocol and the standardized AAOS foot and ankle questionnaire. Radiological evaluation employed standardized anterior-posterior and lateral views. RESULTS: The fragment comprised a median of 24% (range, 10% to 48%) of the articular surface. Postoperative soft tissue problems were encountered in five patients (11%), one of whom required revision surgery. Two patients (4%) developed Stage I complex regional pain syndrome. Clinical and radiological followup at 25 months disclosed no secondary displacement of the fixed fragment. The median foot and ankle score was 93 (range, 58 to 100), shoe comfort score was 77 (range, 0 to 100). A median score of 7 (range, 5 to 16) was documented using the modified Weber protocol. CONCLUSION: The posterolateral approach allowed good exposure and stable fixation of a displaced posterior malleolar fragment with few local complications. The anatomical repositioning and stable fixation led to good functional and subjective outcome.

Internet information and medical consultations: experiences from patients' and physicians' perspectives

OBJECTIVE: Many patients use the Internet to obtain health-related information. It is assumed that health-related Internet information (HRII) will change the consultation practice of physicians. This article explores the strategies, benefits and difficulties from the patients' and physicians' perspective. METHODS: Semi-structured interviews were conducted independently with 32 patients and 20 physicians. Data collection, processing and analysis followed the core principles of Grounded Theory. RESULTS: Patients experienced difficulties in the interpretation of the personal relevance and the meaning of HRII. Therefore they relied on their physicians' interpretation and contextualisation of this information. Discussing patients' concerns and answering patients' questions were important elements of successful consultations with Internet-informed patients to achieve clarity, orientation and certainty. Discussing HRII with patients was appreciated by most of the physicians but misleading interpretations by patients and contrary views compared to physicians caused conflicts during consultations. CONCLUSION: HRII is a valuable source of knowledge for an increasing number of patients. Patients use the consultation to increase their understanding of health and illness. Determinants such as a patient-centred consultation and timely resources are decisive for a successful, empowering consultation with Internet-informed patients. PRACTICAL IMPLICATIONS: If HRII is routinely integrated in the anamnestic interview as a new source of knowledge, the Internet can be used as a link between physicians' expertise and patient knowledge. The critical appraisal of HRII during the consultation is becoming a new field of work for physicians.

The pharmacokinetic profile of fesoterodine: similarities and differences to tolterodine

BACKGROUND: Fesoterodine is a new antimuscarinic agent developed for the treatment of overactive bladder. Fesoterodine itself is inactive and is rapidly and extensively converted by ubiquitous esterases to its principal active moiety, 5-hydroxymethyl tolterodine (5-HMT). 5-HMT is formed via biotransformation of both fesoterodine and tolterodine, albeit by different metabolising enzymes, viz. esterases and CYP2D6 respectively. Tolterodine is a potent muscarinic receptor antagonist and has been used for the treatment of overactive bladder for over ten years. The objective of this study was to establish the pharmacokinetic profile of fesoterodine and to highlight ist potential pharmacokinetic advantages over tolterodine. DESIGN: Single-centre, open-label, randomised, 4-way crossover study in a total of 24 healthy male volunteers. Single oral doses of 4, 8, or 12 mg fesoterodine were administered after an overnight fast. In addition, the 8 mg dose was also administered after a standard high-fat and high-calorie breakfast. Blood and urine samples for the analysis of 5-HMT were collected before and multiple times after drug administration for pharmacokinetic analysis. RESULTS: The mean peak plasma concentration (Cmax) of 5-HMT and the mean area under the time versus concentration curve (AUC) increased proportionally with the fesoterodine dose. These two parameters were some 2-fold higher in CYP2D6 poor metabolisers, whereas the time to peak plasma concentration (tmax) and half life (t1/2) were not influenced by the dose or the CYP2D6 metaboliser status. If fesoterodine was taken following a high-fat breakfast, we observed small increases in Cmax and AUC. In spite of these modest genetic influences and food effects on the pharmacokinetics of fesoterodine, the overall interindividual variability in Cmax levels was relatively little compared to previously published reports using tolterodine. CONCLUSIONS: Due to the esterase-mediated cytochrome P450-independent formation of 5-HMT and involvement of multiple metabolic and renal excretion pathways in the elimination of 5-HMT, the effects of patient-intrinsic and -extrinsic factors on the pharmacokinetics of fesoterodine are only modest, with some 2-fold higher 5-HMT exposure. Therefore, in contrast to tolterodine, no reduction of fesoterodine dosage is required under conditions of reduced elimination. In most cases of drug interaction or renal/hepatic impairment, the fesoterodine dose may be increased to 8 mg/day based on individual patients' response, or patients may be required to remain at the initial recommended dose of 4 mg/day.

Early serum procalcitonin, interleukin-6, and 24-hour lactate clearance: useful indicators of septic infections in severely traumatized patients

BACKGROUND: Elevated lactate and interleukin-6 (IL-6) levels were shown to correlate with mortality and multiple organ dysfunction in severely traumatized patients. The purpose of this study was to test whether an association exists between 24-hour lactate clearance, IL-6 and procalcitonin (PCT) levels, and the development of infectious complications in trauma patients. METHODS: A total of 1757 consecutive trauma patients with an Injury Severity Score (ISS) > 16 admitted over a 10-year period were retrospectively analyzed over a 21-day period. Exclusion criteria included death within 72 h of admission (24.5%), late admission > 12 h after injury (16%), and age < 16 years (0.5%). Data are stated as the median (range). RESULTS: Altogether, 1032 trauma patients (76.2% male) with an average age of 38 years, a median ISS of 29 (16-75), and an Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score of 14 (0-40) were evaluated. The in-hospital mortality (>3 days) was 10%. Patients with insufficient 24-hour lactate clearance had a high rate of overall mortality and infections. Elevated early serum procalcitonin on days 1 to 5 after trauma was strongly associated with the subsequent development of sepsis (p < 0.01) but not with nonseptic infections. The kinetics of IL-6 were similar to those of PCT but did differentiate between infected and noninfected patients after day 5. CONCLUSIONS: This study demonstrates that elevated early procalcitonin and IL-6 levels and inadequate 24-hour lactate clearance help identify trauma patients who develop septic and nonseptic infectious complications. Definition of specific cutoff values and early monitoring of these parameters may help direct early surgical and antibiotic therapy and reduce infectious mortality.

Myc regulates embryonic vascular permeability and remodeling

Previous work has shown that c-Myc is required for adequate vasculogenesis and angiogenesis. To further investigate the contribution of Myc to these processes, we conditionally expressed c-Myc in embryonic endothelial cells using a tetracycline-regulated system. Endothelial Myc overexpression resulted in severe defects in the embryonic vascular system. Myc-expressing embryos undergo widespread edema formation and multiple hemorrhagic lesions. They die between embryonic days 14.5 and 17.5. The changes in vascular permeability are not caused by deficiencies in vascular basement membrane composition or pericyte coverage. However, the overall turnover of endothelial cells is elevated as is revealed by increased levels of both proliferation and apoptosis. Whole-mount immunohistochemical analysis revealed alterations in the architecture of capillary networks. The dermal vasculature of Myc-expressing embryos is characterized by a reduction in vessel branching, which occurs despite upregulation of the proangiogenic factors vascular endothelial growth factor-A and angiopoietin-2. Thus, the net outcome of an excess of vascular endothelial growth factor-A and angiopoietin-2 in the face of an elevated cellular turnover appears to be a defect in vascular integrity.

Assessing vegetation cover and biomass in restored erosion areas in Iceland using SPOT satellite data

Due to highly erodible volcanic soils and a harsh climate, livestock grazing in Iceland has led to serious soil erosion on about 40% of the country's surface. Over the last 100 years, various revegetation and restoration measures were taken on large areas distributed all over Iceland in an attempt to counteract this problem. The present research aimed to develop models for estimating percent vegetation cover (VC) and aboveground biomass (AGB) based on satellite data, as this would make it possible to assess and monitor the effectiveness of restoration measures over large areas at a fairly low cost. Models were developed based on 203 vegetation cover samples and 114 aboveground biomass samples distributed over five SPOT satellite datasets. All satellite datasets were atmospherically corrected, and digital numbers were converted into ground reflectance. Then a selection of vegetation indices (VIs) was calculated, followed by simple and multiple linear regression analysis of the relations between the field data and the calculated VIs. Best results were achieved using multiple linear regression models for both %VC and AGB. The model calibration and validation results showed that R2 and RMSE values for most VIs do not vary very much. For percent VC, R2 values range between 0.789 and 0.822, leading to RMSEs ranging between 15.89% and 16.72%. For AGB, R2 values for low-biomass areas (AGB < 800 g/m2) range between 0.607 and 0.650, leading to RMSEs ranging between 126.08 g/m2 and 136.38 g/m2. The AGB model developed for all areas, including those with high biomass coverage (AGB > 800 g/m2), achieved R2 values between 0.487 and 0.510, resulting in RMSEs ranging from 234 g/m2 to 259.20 g/m2. The models predicting percent VC generally overestimate observed low percent VC and slightly underestimate observed high percent VC. The estimation models for AGB behave in a similar way, but over- and underestimation are much more pronounced. These results show that it is possible to estimate percent VC with high accuracy based on various VIs derived from SPOT satellite data. AGB of restoration areas with low-biomass values of up to 800 g/m2 can likewise be estimated with high accuracy based on various VIs derived from SPOT satellite data, whereas in the case of high biomass coverage, estimation accuracy decreases with increasing biomass values. Accordingly, percent VC can be estimated with high accuracy anywhere in Iceland, whereas AGB is much more difficult to estimate, particularly for areas with high-AGB variability.

Visual complaints and visual hallucinations in Parkinson's disease

Background Visual symptoms are common in Parkinson's disease (PD) and are frequently under-diagnosed. The detection of visual symptoms is important for differential diagnosis and patient management. Aim To establish the prevalence of recurrent visual complaints (RVC) and recurrent visual hallucinations (RVH) and to investigate their interaction in PD patients and controls. Methods This cross-sectional study included 88 PD patients and 90 controls. RVC and RVH were assessed with a visual symptom questionnaire and the North-East-Visual-Hallucinations-Interview (NEVHI). Results Double vision (PD vs. Controls: 18.2% vs. 1.3%; p < 0.001), misjudging objects when walking (PD vs. Controls: 12.5% vs. 1.3%; p < 0.01), words moving whilst reading (PD vs. Controls: 17.0% vs. 1.3%; p < 0.001) and freezing in narrow spaces (PD vs. Controls: 30.7% vs. 0%; p < 0.001) were almost exclusively found in PD patients. The same was true for recurrent complex visual hallucinations and illusions (PD vs. Controls: both 17.0% vs. 0%; p < 0.001). Multiple RVC (43.2% vs. 15.8%) and multiple RVH (29.5% vs. 5.6%) were also more common in PD patients (both p < 0.001). RVC did not predict recurrent complex visual hallucinations; but double vision (p = 0.018, R2 = 0.302) and misjudging objects (p = 0.002, R2 = 0.302) predicted passage hallucinations. Misjudging objects also predicted the feeling of presence (p = 0.010, R2 = 0.321). Conclusions Multiple and recurrent visual symptoms are common in PD. RVC emerged as risk factors predictive of the minor forms of hallucinations, but not recurrent complex visual hallucinations.

Classification and pharmacological treatment of preschool wheezing: changes since 2008.

Since the publication of the European Respiratory Society Task Force report in 2008, significant new evidence has become available on the classification and management of preschool wheezing disorders. In this report, an international consensus group reviews this new evidence and proposes some modifications to the recommendations made in 2008. Specifically, the consensus group acknowledges that wheeze patterns in young children vary over time and with treatment, rendering the distinction between episodic viral wheeze and multiple-trigger wheeze unclear in many patients. Inhaled corticosteroids remain first-line treatment for multiple-trigger wheeze, but may also be considered in patients with episodic viral wheeze with frequent or severe episodes, or when the clinician suspects that interval symptoms are being under reported. Any controller therapy should be viewed as a treatment trial, with scheduled close follow-up to monitor treatment effect. The group recommends discontinuing treatment if there is no benefit and taking favourable natural history into account when making decisions about long-term therapy. Oral corticosteroids are not indicated in mild-to-moderate acute wheeze episodes and should be reserved for severe exacerbations in hospitalised patients. Future research should focus on better clinical and genetic markers, as well as biomarkers, of disease severity.

Framing vulnerability, risk and societal responses: the MOVE framework

The paper deals with the development of a general as well as integrative and holistic framework to systematize and assess vulnerability, risk and adaptation. The framework is a thinking tool meant as a heuristic that outlines key factors and different dimensions that need to be addressed when assessing vulnerability in the context of natural hazards and climate change. The approach underlines that the key factors of such a common framework are related to the exposure of a society or system to a hazard or stressor, the susceptibility of the system or community exposed, and its resilience and adaptive capacity. Additionally, it underlines the necessity to consider key factors and multiple thematic dimensions when assessing vulnerability in the context of natural and socio-natural hazards. In this regard, it shows key linkages between the different concepts used within the disaster risk management (DRM) and climate change adaptation (CCA) research. Further, it helps to illustrate the strong relationships between different concepts used in DRM and CCA. The framework is also a tool for communicating complexity and stresses the need for societal change in order to reduce risk and to promote adaptation. With regard to this, the policy relevance of the framework and first results of its application are outlined. Overall, the framework presented enhances the discussion on how to frame and link vulnerability, disaster risk, risk management and adaptation concepts.

Cochlear implantation in children and adults in Switzerland

The cochlear implant (CI) is one of the most successful neural prostheses developed to date. It offers artificial hearing to individuals with profound sensorineural hearing loss and with insufficient benefit from conventional hearing aids. The first implants available some 30 years ago provided a limited sensation of sound. The benefit for users of these early systems was mostly a facilitation of lip-reading based communication rather than an understanding of speech. Considerable progress has been made since then. Modern, multichannel implant systems feature complex speech processing strategies, high stimulation rates and multiple sites of stimulation in the cochlea. Equipped with such a state-of-the-art system, the majority of recipients today can communicate orally without visual cues and can even use the telephone. The impact of CIs on deaf individuals and on the deaf community has thus been exceptional. To date, more than 300,000 patients worldwide have received CIs. In Switzerland, the first implantation was performed in 1977 and, as of 2012, over 2,000 systems have been implanted with a current rate of around 150 CIs per year. The primary purpose of this article is to provide a contemporary overview of cochlear implantation, emphasising the situation in Switzerland.

Bullous pemphigoid: therapeutic algrorithm and practical management

Introduction: Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucosae. BP typically affects the elderly and manifests with severe itch, localised or generalised eczematous, urticated and/or bullous lesions. Its morbidity and impact on the quality of life are important. The disease is significantly associated with neurological disorders, such as stroke, Parkinson disease, major cognitive impairment and multiple sclerosis. Diagnosis of BP critically relies on immunopathologic examinations, particularly direct immunofluorescence microscopy studies. Areas covered: This paper looks at the evidence of therapies commonly used in bullous pemphigoid. Expert opinion: Treatment of BP has been a challenge, given the relative rarity of the disease, lack of good quality randomised controlled trials, the presence of co-morbidities in the affected elderly population and the high mortality rate. Recent controlled studies have indicated that potent topical corticosteroids constitute a more effective therapy for BP when compared to oral corticosteroids in terms of control of the disease, side effect profile and overall survival. Other therapies have been employed with varying success, but are not validated yet. Improved knowledge of the pathophysiology of BP will hopefully allow the development of new immunomodulatory treatments for this debilitating disease.

Patterns and controls of sediment production, transfer and yield in the Illgraben

Quantification of the volumes of sediment removed by rock–slope failure and debris flows and identification of their coupling and controls are pertinent to understanding mountain basin sediment yield and landscape evolution. This study captures a multi-decadal period of hillslope erosion and channel change following an extreme rock avalanche in 1961 in the Illgraben, a catchment prone to debris flows in the Swiss Alps. We analyzed photogrammetrically-derived datasets of hillslope and channel erosion and deposition along with climatic and seismic variables for a 43 year period from 1963 to 2005. Based on these analyses we identify and discuss (1) patterns of hillslope production, channel transfer and catchment sediment yield, (2) their dominant interactions with climatic and seismic variables, and (3) the nature of hillslope–channel coupling and implications for sediment yield and landscape evolution in this mountain basin. Our results show an increase in the mean hillslope erosion rate in the 1980s from 0.24 ± 0.01 m yr− 1 to 0.42 ± 0.03 m yr− 1 that coincided with a significant increase in air temperature and decrease in snow cover depth and duration, which we presume led to an increase in the exposure of the slopes to thermal weathering processes. The combination of highly fractured slopes close to the threshold angle for failure, and multiple potential triggering mechanisms, means that it is difficult to identify an individual control on slope failure. On the other hand, the rate of channel change was strongly related to variables influencing runoff. A period of particularly high channel erosion rate of 0.74 ± 0.02 m yr− 1 (1992–1998) coincided with an increase in the frequency and magnitude of intense rainfall events. Hillslope erosion exceeded channel erosion on average, indicative of a downslope-directed coupling relationship between hillslope and channel, and demonstrating the first order control of rock–slope failure on catchment sediment yield and landscape evolution.

State-of-the-art aortic imaging: Part II - applications in transcatheter aortic valve replacement and endovascular aortic aneurysm repair.

Transcatheter aortic valve replacement (TAVR) as well as thoracic and abdominal endovascular aortic repair (TEVAR and EVAR) rely on accurate pre- and postprocedural imaging. This review article discusses the application of imaging, including preprocedural assessment and measurements as well as postprocedural imaging of complications. Furthermore, the exciting perspective of computational fluid dynamics (CFD) based on cross-sectional imaging is presented. TAVR is a minimally invasive alternative for treatment of aortic valve stenosis in patients with high age and multiple comorbidities who cannot undergo traditional open surgical repair. Given the lack of direct visualization during the procedure, pre- and peri-procedural imaging forms an essential part of the intervention. Computed tomography angiography (CTA) is the imaging modality of choice for preprocedural planning. Routine postprocedural follow-up is performed by echocardiography to confirm treatment success and detect complications. EVAR and TEVAR are minimally invasive alternatives to open surgical repair of aortic pathologies. CTA constitutes the preferred imaging modality for both preoperative planning and postoperative follow-up including detection of endoleaks. Magnetic resonance imaging is an excellent alternative to CT for postoperative follow-up, and is especially beneficial for younger patients given the lack of radiation. Ultrasound is applied in screening and postoperative follow-up of abdominal aortic aneurysms, but cross-sectional imaging is required once abnormalities are detected. Contrast-enhanced ultrasound may be as sensitive as CTA in detecting endoleaks.

Social Meets Molecular: Combining Phylogenetic and Latent Class Analyses to Understand HIV-1 Transmission in Switzerland

Switzerland has a complex human immunodeficiency virus (HIV) epidemic involving several populations. We examined transmission of HIV type 1 (HIV-1) in a national cohort study. Latent class analysis was used to identify socioeconomic and behavioral groups among 6,027 patients enrolled in the Swiss HIV Cohort Study between 2000 and 2011. Phylogenetic analysis of sequence data, available for 4,013 patients, was used to identify transmission clusters. Concordance between sociobehavioral groups and transmission clusters was assessed in correlation and multiple correspondence analyses. A total of 2,696 patients were infected with subtype B, 203 with subtype C, 196 with subtype A, and 733 with recombinant subtypes (mainly CRF02_AG and CRF01_AE). Latent class analysis identified 8 patient groups. Most transmission clusters of subtype B were shared between groups of gay men (groups 1-3) or between the heterosexual groups "heterosexual people of lower socioeconomic position" (group 4) and "injection drug users" (group 8). Clusters linking homosexual and heterosexual groups were associated with "older heterosexual and gay people on welfare" (group 5). "Migrant women in heterosexual partnerships" (group 6) and "heterosexual migrants on welfare" (group 7) shared non-B clusters with groups 4 and 5. Combining approaches from social and molecular epidemiology can provide insights into HIV-1 transmission and inform the design of prevention strategies.

Neuroimaging findings in cryptogenic stroke patients with and without patent foramen ovale

BACKGROUND AND PURPOSE Patent foramen ovale (PFO) and cryptogenic stroke are commonly associated but some PFOs are incidental. Specific radiological findings associated with PFO may be more likely to indicate a PFO-related cause. We examined whether specific radiological findings are associated with PFO among subjects with cryptogenic stroke and known PFO status. METHODS We analyzed the Risk of Paradoxical Embolism(RoPE) Study database of subjects with cryptogenic stroke and known PFO status, for associations between PFO and: (1) index stroke seen on imaging, (2) index stroke size, (3) index stroke location, (4) multiple index strokes, and (5) prior stroke on baseline imaging. We also compared imaging with purported high-risk echocardiographic features. RESULTS Subjects (N=2680) were significantly more likely to have a PFO if their index stroke was large (odds ratio [OR], 1.36; P=0.0025), seen on index imaging (OR, 1.53; P=0.003), and superficially located (OR, 1.54; P<0.0001). A prior stroke on baseline imaging was associated with not having a PFO (OR, 0.66; P<0.0001). Finding multiple index strokes was unrelated to PFO status (OR, 1.21; P=0.161). No echocardiographic variables were related to PFO status. CONCLUSIONS This is the largest study to report the radiological characteristics of patients with cryptogenic stroke and known PFO status. Strokes that were large, radiologically apparent, superficially located, or unassociated with prior radiological infarcts were more likely to be PFO-associated than were unapparent, smaller, or deep strokes, and those accompanied by chronic infarcts. There was no association between PFO and multiple acute strokes nor between specific echocardiographic PFO features with neuroimaging findings.