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Recently there has been a great deal of interest in the use of biomaterials to stimulate wound healing. This is largely due to their ability to centralize high concentrations of compounds known to promote wound healing at a needed location. Joints present a unique challenge to using scaffolds because of the presence of enzymes in synovial fluid which are known to degrade materials that would be stable in other parts of the body. The hypothesis of this study was that atelocollagen scaffolds would have greater resistance to enzymatic degradation than scaffolds made of gelatin, fibrin and whole blood. To test this hypothesis, collagen and fibrin-based scaffolds were placed in matrix metallopeptidase-1 (MMP-1), elastase, and plasmin solutions at physiologic concentrations, and the degradation of each scaffold was measured at varying time points. The atelocollagen scaffolds had a significantly greater resistance to degradation by MMP-1, elastase and plasmin over the fibrin based scaffolds. The results suggest that atelocollagen-based scaffolds may provide some protection against premature degradation by synovial fluid enzymes over fibrin-based matrices.

C P J / R P C • M A R C H / A P R I L 2 0 1 1 • V O L 1 4 4 , N O 2 Introduction Although chiropractors often practise independently, there is evidence that a growing number are being integrated into multidisciplinary care environments. Co-management, openness to discussion and patient interest have been found to be key factors for developing a chiropractor’s involvement within a collaborative care setting. With the introduction of Bill 179 in Ontario, pharmacists will potentially be able to extend their scope of practice to improve their focus on clinical care activities. The Ontario Government is investing in collaborative care as a means of optimizing access to a wide range of health professionals to make best use of limited resources in the delivery of primary and specialty health care. In an effort to ensure that chiropractors in Ontario are practising to their full potential, a scope of practice review has been recommended by the chiropractic profession. This case report provides an example of the overlap of scopes of practice between pharmacists and chiropractors, emerging as a new common ally group in patient care. Both the pharmacist and chiropractor have been co-located within a family health team (FHT) environment for more than 5 years. Case history A 25-year-old female was referred by her family physician to a chiropractor for nonpharmacological treatment options regarding pregnancy-related low back pain (PLBP). The patient had a history of knee joint pain, flat feet, asthma, iron deficiency and gastroesophageal reflux disease. At the time of presentation, the medication regimen included: • Pulmicort Turbuhaler 200 mcg, one puff twice a day • Bricanyl Turbuhaler 0.5 mg, one puff every 6 hours, as needed • Ferrous fumarate 300 mg, one capsule daily • Diclectin 2 tablets at bedtime, 1 tablet in the morning and 1 tablet at noon • Acetaminophen 325 mg, 1–2 tablets every 6 hours for pain, as needed The patient was self-medicating with the acetaminophen 325 mg for PLBP, with minimal benefit. The patient presented with progressively worsening neck, middle and low back pain. These symptoms were limiting her ability to work. The chiropractor initiated care that included spinal manipulation, education on posture, muscle techniques and pacing strategies and pregnancyspecific exercises. Chiropractors and pharmacists in a family health team: Unlikely allies in the collaborative management of pregnancy-related low back pain

The effect of prosthesis-patient mismatch on long-term survival after mitral valve replacement (MVR) has received limited attention. This study was performed to determine the predictors of mortality after MVR and influence of prosthesis-patient mismatch on survival.Contemporary mechanical prostheses and bioprostheses were implanted in 2,440 patients with MVR between 1982 and 2002. The mean age was 63.9 +/- 12.1 years and the mean follow-up was 6.1 +/- 4.6 years, a total of 14,797.7 years of follow-up. Prosthesis-patient mismatch was classified by effective orifice area index categories: normal, greater than 1.2 cm(2)/m(2) (345, 14.2%); mild-to-moderate, equal to or less than 1.2 to greater than 0.9 cm(2)/m(2) (1,696, 69.5%); and severe, equal to or less than 0.9 cm(2)/m(2) (399, 16.4%).The predictors of overall mortality were age, age categorization, New York Heart Association III-IV, concomitant coronary artery bypass, ventricular dysfunction, prosthesis type, body mass index, and pulmonary hypertension. All categories of effective orifice area indices (EOAIs) were not predictive of overall mortality, late mortality, or early mortality. The 15-year survival was not differentiated by EOAI categories; 32.0 +/- 4.4%, 32.9 +/- 2.1%, and 36.6 +/- 6.3%, respectively, for the three categories. Pulmonary hypertension influenced mortality by EOAI categories; normal versus mild-to-moderate (p = 0.0317) and normal versus severe (p = 0.0320). The EOAI was not an independent predictor of mortality in the consideration of patients with pulmonary hypertension but there is an interaction between pulmonary hypertension and mild-to-moderate (p = 0.023) and severe (p = 0.031) EOAI.Prosthesis-patient mismatch is not a predictor of overall mortality to 15 years after MVR regardless of the category of effective orifice area index. The preoperative variable, pulmonary hypertension, influences overall mortality in the presence of mild-to-moderate and severe prosthesis-patient mismatch in the survival analysis.

Recurrent pains are a complex set of conditions that cause great discomfort and impairment in children and adults. The objectives of this study were to (a) describe the frequency of headache, stomachache, and backache in a representative Canadian adolescent sample and (b) determine whether a set of psychosocial factors, including background factors (i.e., sex, pubertal status, parent chronic pain), external events (i.e., injury, illness/hospitalization, stressful-life events), and emotional factors (i.e., anxiety/depression, self-esteem) were predictive of these types of recurrent pain. Statistics Canada's National Longitudinal Survey of Children and Youth was used to assess a cohort of 2488 10- to 11-year-old adolescents up to five times, every 2 years. Results showed that, across 12-19 years of age, weekly or more frequent rates ranged from 26.1%-31.8% for headache, 13.5-22.2% for stomachache, and 17.6-25.8% for backache. Chi-square tests indicated that girls had higher rates of pain than boys for all types of pain, at all time points. Structural equation modeling using latent growth curves showed that sex and anxiety/depression at age 10-11 years was predictive of the start- and end-point intercepts (i.e., trajectories that indicated high levels of pain across time) and/or slopes (i.e., trajectories of pain that increased over time) for all three types of pain. Although there were also other factors that predicted only certain pain types or certain trajectory types, overall the results of this study suggest that adolescent recurrent pain is very common and that psychosocial factors can predict trajectories of recurrent pain over time across adolescence.

Accurate pain assessment is the foundation for effective pain management in children. At present, there is no clear consensus regarding the age at which young children are able to appropriately use self-report scales for pain. This study examined young children's ability to use the Faces Pain Scale-Revised; (FPS-R; [Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001; 93: 173-83]) for pain in response to vignettes and investigated the role of developmental factors in predicting their ability to use the scale. One hundred and twelve healthy children (3-6 years old) were assessed for their ability to accurately use a common faces scale to rate pain in hypothetical vignettes depicting pain scenarios common in childhood. Accuracy was determined by considering whether children's judgements of pain severity matched the pain severity depicted in the various vignettes. Children were also administered measures of numerical reasoning, language, and overall cognitive development. Results indicated that 5- and 6-year-old children were significantly more accurate in their use of the FPS-R in response to the vignettes than 4-year-old children, who in turn were significantly more accurate than 3-year-old children. However, over half of the 6-year-olds demonstrated difficulties using the FPS-R in response to the vignettes. Child age was the only significant predictor of children's ability to use the scale in response to the vignettes. Thus, a substantial number of young children experienced difficulties using the FPS-R when rating pain in hypothetical vignettes, although the ability to use the scale did improve with age.

ObjectiveThe Artificial Valve Endocarditis Reduction Trial was stopped on January 21, 2000, due to a higher incidence of paraprosthetic leak in the St Jude Medical Silzone prosthesis compared with the conventional prosthesis. The Artificial Valve Endocarditis Reduction Trial investigators reported the 2-year results in 2002. This retrospective study assessed the influence on thromboembolism and paraprosthetic leak to 7 years.MethodsA total of 253 patients had 254 operations: 80 aortic valve replacements, 139 mitral valve replacements, and 35 multiple replacements with placement of Silzone prostheses. The mean age was 58.6 years (range 21–84 years, median age 59.8 years), and there were 126 women (49.8%) and 74 concomitant procedures (coronary artery bypass 28.9%).ResultsMajor paraprosthetic leak (repair, re-replacement, or mortality) occurred in 10 of the original procedures after 30 days (3 aortic valve replacements, 3 mitral valve replacements, 4 multiple replacements). Nine occurrences in 8 patients—5 early (≤2 years) and 4 late (>2 years)—were managed. Seven were managed with definitive re-replacement. One was an early nonoperative fatality. There was 1 late fatality after the second late paraprosthetic leak reoperation. One of the 10 procedures occurring after 2 years had mild to moderate aortic valve replacement paraprosthetic leak managed as an incidental re-replacement at the time of correction of supra valvular patch stenosis. One additional occurrence, in addition to the 8 patients (2years) intervals with re-replacement. Late managed events may be manifestations of earlier occurring paraprosthetic leak. Follow-up echocardiograms should meet standards of care, 6 to 12 months after surgery and at the slightest suspicion of dysfunction. There is no advanced continuing risk of the St Jude Medical Silzone prosthesis.