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Abstract Background Propionic acidemia is an inherited disorder caused by deficiency of propionyl-CoA carboxylase. Although it is one of the most frequent organic acidurias, information on the outcome of affected individuals is still limited. Study design/methods Clinical and outcome data of 55 patients with propionic acidemia from 16 European metabolic centers were evaluated retrospectively. 35 patients were diagnosed by selective metabolic screening while 20 patients were identified by newborn screening. Endocrine parameters and bone age were evaluated. In addition, IQ testing was performed and the patients’ and their families’ quality of life was assessed. Results The vast majority of patients (>85%) presented with metabolic decompensation in the neonatal period. Asymptomatic individuals were the exception. About three quarters of the study population was mentally retarded, median IQ was 55. Apart from neurologic symptoms, complications comprised hematologic abnormalities, cardiac diseases, feeding problems and impaired growth. Most patients considered their quality of life high. However, according to the parents’ point of view psychic problems were four times more common in propionic acidemia patients than in healthy controls. Conclusion Our data show that the outcome of propionic acidemia is still unfavourable, in spite of improved clinical management. Many patients develop long-term complications affecting different organ systems. Impairment of neurocognitive development is of special concern. Nevertheless, self-assessment of quality of life of the patients and their parents yielded rather positive results.

Abstract Background The evaluation, verification and comparison of different numerical heart models are difficult without a commonly available database that could be utilized as a reference. Our aim was to compile an exemplary dataset. Methods The following methods were employed: Magnetic Resonance Imaging (MRI) of heart and torso, Body Surface Potential Maps (BSPM) and MagnetoCardioGraphy (MCG) maps. The latter were recorded simultaneously from the same individuals a few hours after the MRI sessions. Results A training dataset is made publicly available; datasets for blind testing will remain undisclosed. Conclusions While the MRI data may provide a common input that can be applied to different numerical heart models, the verification and comparison of different models can be performed by comparing the measured biosignals with forward calculated signals from the models.

Abstract Background The signal recognition particle (SRP) receptor plays a vital role in co-translational protein targeting, because it connects the soluble SRP-ribosome-nascent chain complex (SRP-RNCs) to the membrane bound Sec translocon. The eukaryotic SRP receptor (SR) is a heterodimeric protein complex, consisting of two unrelated GTPases. The SRβ subunit is an integral membrane protein, which tethers the SRP-interacting SRα subunit permanently to the endoplasmic reticulum membrane. The prokaryotic SR lacks the SRβ subunit and consists of only the SRα homologue FtsY. Strikingly, although FtsY requires membrane contact for functionality, cell fractionation studies have localized FtsY predominantly to the cytosolic fraction of Escherichia coli. So far, the exact function of the soluble SR in E. coli is unknown, but it has been suggested that, in contrast to eukaryotes, the prokaryotic SR might bind SRP-RNCs already in the cytosol and only then initiates membrane targeting. Results In the current study we have determined the contribution of soluble FtsY to co-translational targeting in vitro and have re-analysed the localization of FtsY in vivo by fluorescence microscopy. Our data show that FtsY can bind to SRP-ribosome nascent chains (RNCs) in the absence of membranes. However, these soluble FtsY-SRP-RNC complexes are not efficiently targeted to the membrane. In contrast, we observed effective targeting of SRP-RNCs to membrane-bond FtsY. These data show that soluble FtsY does not contribute significantly to cotranslational targeting in E. coli. In agreement with this observation, our in vivo analyses of FtsY localization in bacterial cells by fluorescence microscopy revealed that the vast majority of FtsY was localized to the inner membrane and that soluble FtsY constituted only a negligible species in vivo. Conclusion The exact function of the SRP receptor (SR) in bacteria has so far been enigmatic. Our data show that the bacterial SR is almost exclusively membrane-bound in vivo, indicating that the presence of a soluble SR is probably an artefact of cell fractionation. Thus, co-translational targeting in bacteria does not involve the formation of a soluble SR-signal recognition particle (SRP)-ribosome nascent chain (RNC) intermediate but requires membrane contact of FtsY for efficient SRP-RNC recruitment.

Background and Objectives: Proximal humerus fractures are the second most frequent site of avascular necrosis (AVN), occurring in up to 16% of cases. The Hertel criteria have been used as a reference for the prediction of humerus head ischemia. However, these are based solely on the use of radiographs, which can make interpretation extremely difficult due to several reasons, such as the overlapping fragments, severity of the injury, and noncompliant acute pain patients. The objectives of the study were to evaluate the role of computed tomography (CT) in the interpretation of the Hertel criteria and to evaluate the intra- and interobserver agreement of orthopedic surgeons, comparing their area of expertise. Materials and Methods: The radiographs and CT scans of 20 skeletally mature patients who had fractures of the proximal humerus were converted to jpeg and mov, respectively. All images were evaluated by eight orthopedic surgeons (four trauma surgeons and four shoulder surgeons) in two different occasions. The intra- and interobserver agreement was assessed by using the Kappa coefficient. The level of significance was 5%. Results: There was a weak-to-moderate intraobserver agreement (κ < 0.59) for all examiners. Only the medial metaphyseal hinge greater than 2 mm was identified by 87.5% of evaluators both in the radiographic and CT examinations in the two rounds of the study (p < 0.05). There was no significant interobserver agreement (κ < 0.19), as it occurred only in some moments of the second round of evaluation. Conclusions: The prognostic criteria for humeral head ischemia evaluated in this study showed weak intra- and interobserver agreement in both the radiographic and tomographic evaluation. CT did not help surgeons in the primary interpretation of Hertel prognostic criteria used in this study when compared to the radiographic examination.

Articular fractures of the distal humerus in adults are challenging fractures requiring adequate surgical exposure for optimum reconstruction. Most commonly, an articular osteotomy of the olecranon is performed, but complications have been reported related to both creating and repairing the articular osteotomy. We describe the use of an extra-articular olecranon osteotomy for approaching articular fractures of the distal humerus. We highlight the surgical steps required to obtain adequate exposure facilitating anatomical reduction, stable fixation, and early range of motion of the elbow joint. This technique can be added to the surgeon's armamentarium for the management of these complex injuries. [ Orthopedics . 2022;45(4):e220-e225.].

Purpose: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm., Patients and Methods: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union., Results: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05)., Conclusion: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Our objective is to describe the technique of intramedullary (IM) nailing of lateral malleolus in the surgical management of ankle fractures. Fracture reduction is performed either percutaneously with a small pointed reduction clamp in simple oblique fractures or using longitudinal traction and rotation for comminuted fractures, thus reducing complications related to open reduction and internal fixation with a plate. The technique has been shown to be simple and reproducible. In addition, the technique allows early weight bearing, which accelerates rehabilitation and potentially fasten fracture healing. IM nailing is a viable option for the fixation of the of lateral malleolus in ankle fractures and should be considered in the surgeon's armamentarium.

The aim of this study was to evaluate the biomechanical role of both a non-locking two-hole small fragment dynamic compression plate with 3.5-mm screws and a 4.5-mm cortical screw with a washer applied to a Schatzker type-I tibial plateau fracture. Sixteen right synthetic tibiae were used to create an anterolateral shear tibial plateau fracture (Schatzker type-I fracture). Eight models were fixed with a small fragment non-locked straight dynamic compression plate with one 3.5-mm bicortical screw (plate-screw construction) and eight models were fixed with a 4.5-mm cortical screw and a washer (screw-washer construction), both inserted at 1.0 mm distal to the apex of the fracture. Specimens were tested up to the onset of yielding at a constant strain rate of 5.0-mm/min. Stiffness ranged from 311.83 N/mm to 199.54 N/mm, with a mean + SD of 260.32 + 33.8 N/mm in the plate-screw construction, and from 290.34 N/mm to 99.16 N/mm, with a mean + SD of 220.46 + 63.12 N/mm in screw-washer construction. There was no significant difference (p=0.172). Use of a two-hole small-fragment non-locked plate with one 3.5-mm cortical screw or a 4.5-mm cortical screw with a washer applied at 1.0 mm distal to the apex of the fracture as buttressing present similar stiffness in terms of preventing axial displacement in synthetic tibiae models tested up to the onset of yielding.

Purpose: The aim of this study is to compare the biomechanical behavior of three different fixation constructions currently used for buttressing the posteromedial shearing tibial plateau fragment. Our hypothesis is that non-locked implants provide sufficient comparable stability in posteromedial tibial plateau fractures as locked implants., Methods: Fifteen left synthetic tibiae from a single manufacturing batch were used to create a posteromedial shear tibial plateau fracture. The fracture was buttressed with three different posteriorly placed five-hole straight small-fragment plate. Five models were fixed with a one-third tubular plate (TTP), five models with a dynamic compression plate (DCP), and five models with a locking compression plate (LCP). All groups were tested to vertical subsidence (Stage 1). In the same experiment (Stage 2), TTP and DCP groups were tested until catastrophic failure. Force versus displacement curves were obtained in the two stages of the experiment., Results: Stage 1 - There was no significant difference in stiffness (p = 0.89), subsidence up to 2 mm (p = 0.38), and energy (p = 0.36) among the three fixation constructions. Stage 2 - Yield load revealed significantly less yield strength for the TTP group as compared with the DCP group (p = 0.048). However, there was no significant difference in maximum load to failure among the TTP and DCP fixation constructions (p = 0.16)., Conclusion: Placement of either a locked or non-locked small fragment straight plate to buttress the posteromedial shear tibial plateau fragment has a similar biomechanical behavior. When the implant is positioned to buttress the shearing fragment it maximizes biomechanical stiffness.

Objective To describe functional and quality of life results after extended supratracheal laryngectomy. Methods In the period from September 2009 to January 2018, 11 male subjects were submitted to extended supratracheal laryngectomy. Swallowing abilities were assessed through videofluoroscopy and the clinical scale Functional Communication Measures of Swallowing. The voices were classified by means of the perceptual-auditory analysis Consensus Auditory-Perceptual Evaluation of Voice. All subjects completed a self-assessment questionnaire for voice and swallowing. Results Aspiration was found in four patients and all presented stasis in different structures. All subjects in this study were exclusively orally fed and hydrated. In the evaluation of quality of life in swallowing, patients had mean >80 in all areas (83.47 mean of scores). The general degree and the presence of roughness were the highest means present in Consensus Auditory-Perceptual Evaluation of Voice (37.81 and 49.36, respectively). The mean of 33.36 (±22.56) had little impact on quality of life under the perspective of vocal aspects. Conclusion After supratracheal laryngectomy, swallowing was sufficiently restored and the quality of life was satisfactory. The voice presents severely impaired quality and preserved oral communication, with low impact on the activities of daily living. All individuals who maintained two cricoarytenoid units presented better functional results in swallowing and voice.

Background: The purpose of this study was to evaluate the role of a non-locking plate applied to the anteromedial surface of the proximal humerus on loads at the implant-bone interface of non-locking and locking lateral plate fixation of proximal humeral fractures with a medial gap., Methods: Twenty synthetic humeri models were used. In fifteen, the proximal portion of the humerus was osteotomized to create a two-part surgical neck fracture, with a 10-mm medial gap and a 5-mm lateral gap; five models were controls. In the osteotomized humeri, five models were stabilized with a locking lateral plate (group L), five with a locking lateral plate and an anteromedial non-locking plate (group L+T), and five with a non-locking lateral plate and a non-locking anteromedial plate (group T+T). All humeri were tested under axial loading until catastrophic failure, which was characterized as complete closure of the medial gap. Stiffness was calculated using force vs. displacement curves. The data were analyzed via descriptive and inferential studies, at a 5% significance level., Results: Statistically significant differences were seen among all the constructions. The combination of a lateral locking plate with an anteromedial non-locking plate (group L+T) was the stiffest construction, while the combination of a non-locking lateral plate with a non-locking anteromedial plate (group T+T) was the least stiff, even in comparison with a single locking lateral plate (p = 0.01). When the two groups which utilized a lateral locking plate (groups L+T and L) were compared, the group with additional anteromedial support demonstrated greater stiffness (p = 0.03), and stiffness values for the control group comprised of intact humeri models were even higher (p = 0.01)., Conclusion: Combining a lateral locking plate with a non-locking anteromedial plate provides a stiffer construction for fixation of unstable two-part proximal humerus fractures with a medial gap. Mechanical benefits of medial support with a second non-locking antero-medial plate seems to be related with better construct stability in terms of strength and fatigue, potentially reducing the risk of varus collapse of the humerus head and fracture healing disturbances., Competing Interests: The authors have declared that no competing interests exist.

Background: The biomechanical behavior of Pauwels type III fractures should be taken into consideration when performing internal fixation, since this repair should resist the shear force inherent in the vertical fracture line to the greatest extent possible. Recently, the use of a small fragment plate on the medial face of the femoral neck has been proposed by some authors, with satisfactory initial results. In the current study we analyze the mechanical role a medial plate used as a buttress plate for Pauwels type III femoral neck fractures, comparing the resistance of two fixation configurations using three cannulated screws., Methods: Pauwels type III fractures were simulated in synthetic bones models and two groups were created, one of those using two parallel screws at the bottom of the femoral neck and the third screw crossing the fracture horizontally (G1), and the other fixed in the same arrangement as G1, but with the addition of a medial side plate at the apex of the fracture (G2). The constructs were subjected to axial loading until catastrophic failure., Results: The addition of a medial plate buttressing the femoral neck increased significantly the resistance to maximum loading (p = 0.003)., Conclusion: Use of a medial buttress plate results in a mechanically superior construction for Pauwels type III fractures fixed with multiple cannulated screws., Lebel of Evidence: Level IV. Biomechanical comparative study.

Objective  The aim of the present study was to evaluate the practices and preferences of Brazilian orthopedic surgeons for the treatment of femoral neck fractures in middle-aged patients. Methods  A survey containing 10 images of femoral neck fractures was sent to a group of 100 orthopedic surgeons, all of them members of the Brazilian Society of Orthopedics and Traumatology. The questionnaire asked the treatment option for cases of nondisplaced and displaced fractures of the femoral neck in middle-aged patients, that is, those between 50 and 69 years old. Descriptive and inferential statistical analyzes were performed using the chi-squared (χ2) and the Fisher exact tests. The level of significance was 5%. Results  The survey was answered by 78% of the orthopedic surgeons invited to participate in the study. There was no significant difference in the treatment method distribution between generalists and specialists ( p  = 0.16) in the sample of nondisplaced femoral neck fractures. There was a highly significant difference in the treatment method distribution between generalists and specialists ( p  < 0.0001) in the sample of displaced fractures of the femoral neck. Conclusion  Preservation of the femoral head through multiple cannulated screws fixation is the treatment of choice for nondisplaced femoral neck fractures for both generalists and specialists. Low chronological and/or physiological age are the main factors for this decision-making. In displaced femoral neck fractures, femoral head replacement is preferred for both groups of orthopedists (generalists and specialists). In this situation, specialists prefer total hip arthroplasty (THA), whereas generalists favor partial hip arthroplasty (PHA).

Femoral head fractures occur almost exclusively as a result of a traumatic hip dislocation. Treatment is typically an emergency and includes the reduction of the dislocated hip under anesthesia. As a rule, the earlier the reduction, the better the outcome. Open reduction and internal fixation of the fracture of the femoral head is the treatment of choice for most young patients. In some selected cases when there is a very small fragment located in the region below the fovea, removal should be indicated. In elderly patients and those who experience severe femoral head impaction, it is preferable to perform a total hip replacement. Despite optimal management, the rate of complications after femoral head fractures may reach as high as 50%. In the present study, the authors review the general principles of management of patients with femoral head fractures.

Purpose: The aim of our study is to compare the mechanical resistance of two screw configurations in fixating type II Pauwels femoral neck fractures., Methods: Fifteen synthetic models of femur bones in young adults were divided into three equal groups: intact (G1), models with fixation of a 5.0-mm failure zone created in the posterior cortex of the femoral neck using an L-shaped screw arrangement (G2, n = 5), and models with an identical failure zone fixated using an inverted triangle assembly (G3, n = 5). Model strength (axial loading) and rotational deviation of the fragments were load-tested until a 5.0-mm displacement was reached (step 1) and then until failure, here considered as 10.0 mm displacement in G2 and G3 or femoral neck fracture in G1 (step 2)., Results: In step 1, the mean resistance in G1 was 1593 N (standard deviation [SD] of 62 N); this value in G2 was 1261 N (SD 49 N) and in G3 was 1074 N (SD 153 N). During step 2, the value for G1 was 2247 N (SD 84 N), for G2 was 1895 N (SD 69 N), and for G3 was 1523 N (SD 280 N). G3 (the inverted triangle assembly) showed a significantly lower maximum load than the group using the L-shaped assembly (G2) and the control group (G1), which was significant using Kruskal-Wallis analysis of variance (p = 0.002)., Conclusion: Under test conditions in synthetic bone, fixation using a L-shaped screw assembly provides greater mechanical resistance than an inverted triangle assembly.

Objective The primary aim of this study was to survey current practices and preferences behind internal fixation of trochanteric femoral fractures among Brazilian orthopedic surgeons. The secondary aim was to identify the main reason for these preferences. Methods A survey containing 20 images of trochanteric fractures of the femur was presented to a group of 62 orthopedists, all members of the Brazilian Society of Orthopedics and Traumatology (SBOT). The first part of the questionnaire was created to identify the surgeons' degree of professional experience, type of practice, and areas of greatest interest and performance within the specialty. The second part of the questionnaire contained options for fixating different trochanteric fracture patterns in the femur for participants to choose, along with the main reason for their decision. Statistical analysis was descriptive and profiled the surgeons' major area of interest, treatment option, and the main reason for their therapeutic decision. Results Of the 62 orthopedists who participated in the study, 10 (16.0%) stated that their area of greatest interest was orthopedic trauma and 52 (83.9%) reported greater interest in another area of the specialty; these two groups were classified as the Trauma Group and Orthopedics Group, respectively. To treat AO 31A1 type fractures, the trauma group selected the sliding hip screw (SHS) in 66.7% of cases, while the orthopedics group chose the SHS in 65.8% of cases. For 31A2 type fractures, the trauma group chose the intramedullary (IM) nail in 64.0% of the cases, while the orthopedics group chose the IM nail in 76.7% of the cases. For 31A3 type fractures, the trauma group opted for the IM nail in 70.0% of the cases, while the orthopedics group selected the IM nail in 88.0% of the cases. The two most important factors in implant selection for the three types of fracture were fracture pattern and implant availability. Conclusion The sliding hip screw is preferred by most Brazilian orthopedic surgeons for fixation of 31A1 type trochanteric femoral fractures. For 31A2 and 31A3 type fractures, the IM nail is preferred., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine the ideal working area for a simple transverse fracture line treated with a bridge plate., Methods: A 2-D finite element analysis of a hypothetical femur was performed for the quantitative evaluation of a large-fragment titanium alloy locking plate based on the precept of relative stability in a case of a simple transverse diaphyseal fracture. Two simulations (one case of strain and another case of stress distribution) were analyzed in three unique situations according to the von Mises stress theory. Load distributions were observed when the bone was subjected to a single vertical load of 1000 N., Results: The longer the length of the implant flexion, which coincided with the working area of the plate, the greater the flexion of the implant. The highest concentrations of stress on the plate occurred in the region around the screws closest to the bone gap. The closer the screws to the fracture site, the greater the demands on the plate., Conclusion: When using a large-fragment titanium alloy locking plate to stabilize a simple transverse fracture based on the precept of relative stability (bridge plate), there must be considerable distance between the proximal and distal screws closest to the fracture line. The farther away this fixation is, the lower the stress on the plate and the greater the dissipation of force in the form of deflection.

Background: The universal accepted strategy for treating high-energy tibial plateau fractures remains a topic of ongoing debate. The challenge for the practicing orthopaedic trauma surgeon is to provide anatomical articular fracture reduction, with successfully managing the complex soft-tissue injury that is commonly present at patient admission. The primary aim of the actual study was to evaluate the results of a staged protocol for the treatment of high-energy bicondylar tibial plateau fractures. The secondary aim was to describe the technique used for the definitive fixation of this complex fracture pattern., Methods: Thirty patients with unstable high-energy closed bicondylar tibial plateau fractures (17 Schatzker V and 13 Schatzker VI) were managed. There were 24 men (80%) and six women (20%). All of them were skeletally mature with their age ranging from 19 to 67 years (mean of 33.1±3.4 years). Treatment involved a two-stage procedure with appropriate emergency care, preoperative planning, and definitive fixation. Initial treatment, named 'damage control on complex articular fracture elements', consisted on temporary bridging external fixation. Definitive treatment was delayed in a mean of 10 days (ranging from seven to 13 days) and was performed when the soft-tissue conditioning demonstrated either complete or almost complete remission of the inflammatory reaction due to the 'first hit'. Conventional implants were used in the 30 patients. All patients were evaluated clinically and radiographically., Results: Twenty-six (86.7%) patients had a moderate level of activity, three (10%) patients had a very light level of activity, and one (3.3%) patient was unable to have any kind of work activity and is currently supported by the Brazilian Welfare. Using the visual analog scale mean pain score was 30 (ranging from 10 to 60); even the patient with the workers' compensation had no severe pain. All patients except three have no difficulty with stairs, giving way, locking, swelling, and squatting, but were unable to run. Three (10%) patients had problems with stairs and could not bend the operated knee more than 90 ° . One of them had a varus knee but no instability. Ninety percent of the patients were either very satisfied or somewhat satisfied with their outcome. The three dissatisfied patients suffered postoperative complications, most commonly wound infections. Four (13.4%) patients with former anatomical reduction had a residual articular step-off or diastasis of less than 3mm after fracture healing. All patients had no or mild arthrosis at the time of the last outpatient consultation., Conclusions: The two-staged procedure presented herein showed to be an effective strategy for managing bycondilar tibial plateau fractures. The protocol used for these complex traumatic injuries follows very well defined steps, which means acute stabilization with a linear bridging external fixation, adequate soft tissue handling, preoperative planning, and definitive surgical fixation after seven to 14 days. The model presents a more biological approach to optimizing functional outcome with an acceptable complication rate and minimal risk of loss of reduction in these high-energy tibial plateau fractures., (© 2017 Elsevier Ltd. All rights reserved.)

Competing Interests: Conflito de interesse: Os autores declararam não haver conflitos de interesse que precisam ser informados.

Background: Open pelvic fractures are rare but usually associated with a high incidence of complications and increased mortality rates. The aim of this study was to retrospectively evaluate all consecutive open pelvic fractures in patients treated at a single Level-1 Trauma Center during a 10-year interval., Patients and Methods: In a 10-year interval, 30 patients with a diagnosis of open pelvic fracture were admitted at a Level-1 Trauma Center. A retrospective analysis was conducted on data obtained from the medical records, which included patient's age, sex, mechanism of injury, classification of the pelvic lesion, Injury Severity Score (ISS), emergency interventions, surgical interventions, length of hospital and Intensive Care Unit stay, and complications, including perioperative complications and death. The Jones classification was used to characterize the energy of the pelvic trauma and the Faringer classification to define the location of the open wound. Among the survivors, the results were assessed in the last outpatient visit using the EuroQol EQ-5D and the Blake questionnaires. It was established the relationship between the mortality and morbidity and these classification systems by using the Mann-Whitney non-parametric test, with a level of significance of 5%., Results: Twelve (40%) patients died either from the pelvic lesion or related injuries. All of them had an ISS superior to 35. The Jones classification showed a direct relationship to the mortality rate in those patients (p = 0.012). In the 18 (60%) other patients evaluated, the mean follow-up was 16.3 months, ranging from 24 to 112 months. Eleven (61%) patients had a satisfactory outcome. The Jones classification showed a statistically significant relationship both to the objective and subjective outcomes (p < 5%). The Faringer classification showed a statistically significant relationship to the subjective, but not to the objective outcome. In addition, among the 18 patients evaluated at the last outpatient visit, the Faringer classification showed statistical significance on the need of colostomy (p = 0.001) in the acute phase of treatment., Conclusion: We suggest the routine use of the Jones classification for the emergency room assessment and management of all open fractures of the pelvic ring. We believe the Faringer classification seems to be useful for the abdominal surgeons for the indication of gut transit derivation but not for the acute management of the bony component of an open pelvic fracture.

Objective: : to evaluate the histologic and morphometric characteristics of bone biopsies of the anterior iliac crest of patients of different age groups., Methods: : we studied 30 bone samples from the iliac crest, using brightfield optical microscopy. We divided the samples by donors' age groups in three groups: Group 1 (n = 10), subjects aged between 25 and 39 years; Group 2 (n = 10), subjects aged between 40 and 64 years; Group 3 (n = 10), individuals aged 65 years and over. We randomly divided the samples into two sets with 15 specimens. In the first study segment (n = 15), we used histological to assess the osteogenic property of the graft, through the analysis of cell reserve in the periosteum, the number of osteocytes in the lacunae and the number of Haversian and Volkmann's canals. In the second study segment (n = 15), we investigated the morphology of osteoconductive property of the graft, through quantification of the trabecular meshwork (Vv) and trabecular area (Sv)., Results: : histologically, we observed degeneration of bone occurring with age, characterized by thinning of the periosteum, with gradual replacement of the steogenic layer by fibrous tissue, small amount of Haversian and Volkmann's canals, osteocyte lacunae voids and fine spongy bone trabeculae, allowing ample medullary space, usually occupied by fat cells and adipocytes. Morphologically, with respect to the quantification of the trabecular meshwork (Vv), we found statistically significant differences between Groups 1 and 3 and between Groups 2 and 3, with reduction of the trabecular meshwork of about 45% in the elderly over 65 years old ; there was no statistically significant difference between Groups 1 and 2. There was also no statistical difference between the Groups regarding Sv., Conclusion: : the results of this experiment suggest that, in the elderly (over 65 years old), the osteogenic property of autologous bone graft decreases and the osteoconductive property is compromised., Objetivo: avaliar as características histológicas e morfométricas de biópsias ósseas da região anterior da crista ilíaca de pacientes de diferentes faixas etárias., Métodos: foram estudadas 30 amostras de osso da crista ilíaca, utilizando-se microscopia óptica de campo claro. As amostras foram divididas pela faixa etária dos doadores em três grupos: Grupo 1 (n = 10), indivíduos com idade entre 25 e 39 anos; Grupo 2 (n = 10), indivíduos com idade entre 40 e 64 anos; Grupo 3 (n = 10), indivíduos com idade igual ou superior a 65 anos. As amostras foram separadas aleatoriamente em dois conjuntos com 15 peças. No primeiro segmento do estudo (n = 15), foi avaliada histologicamente a propriedade osteogênica do enxerto, através da análise da reserva celular no periósteo, do número de osteócitos nas lacunas e da quantidade de canais de Havers e de Volkmann. No segundo segmento do estudo (n = 15), investigou-se morfologicamente a propriedade osteocondutora do enxerto, através da quantificação da rede trabecular (Vv) e da área trabecular (Sv)., Resultados: histologicamente, observou-se que ocorre degeneração do tecido ósseo com a idade, caracterizada pelo adelgaçamento do periósteo, com substituição gradual da camada osteogênica por tecido fibroso, pequena quantidade de canais de Havers e de Volkmann, osteoplastos vazios e trabéculas finas de osso esponjoso, permitindo amplo espaço medular, em geral ocupado por células lipídicas e adipócitos. Morfologicamente, com relação à quantificação da rede trabecular (Vv), foi observada diferença estatisticamente significante entre os Grupos 1 e 3 e entre os Grupos 2 e 3, com redução da rede trabecular de cerca de 45% no idoso acima de 65 anos de idade; não foi observada diferença estatisticamente significante entre os Grupos 1 e 2. Não foi observada diferença estatística entre os grupos quanto à Sv., Conclusão: os achados do presente experimento sugerem que nos indivíduos idosos (acima de 65 anos de idade), a propriedade osteogênica do enxerto ósseo autólogo diminui e a propriedade osteocondutora está comprometida.

Objective: The aim of this study was to evaluate the inter- and intra-observer agreement in the initial diagnosis and classification by means of plain radiographs and CT scans of tibial plateau fractures photographed and sent via WhatsApp Messenger., Background: The increasing popularity of smartphones has driven the development of technology for data transmission and imaging and generated a growing interest in the use of these devices as diagnostic tools. The emergence of WhatsApp Messenger technology, which is available for various platforms used by smartphones, has led to an improvement in the quality and resolution of images sent and received., Methods: The images (plain radiographs and CT scans) were obtained from 13 cases of tibial plateau fractures using the iPhone 5 (Apple Inc., Cupertino, CA, USA) and were sent to six observers via the WhatsApp Messenger application. The observers were asked to determine the standard deviation and type of injury, the classification according to the Schatzker and the Luo classifications schemes, and whether the CT scan changed the classification. The six observers independently assessed the images on two separate occasions, 15 days apart., Results: The inter- and intra-observer agreement for both periods of the study ranged from excellent to perfect (0.75<κ<1.0) across all survey questions. When asked if the inclusion of the CT images would change their final X-ray classification (Schatzker or Luo), the inter- and intra-observer agreement was perfect (k=1) on both assessment occasions., Conclusion: We found an excellent inter- and intra-observer agreement in the imaging assessment of tibial plateau fractures sent via WhatsApp Messenger. The authors now propose the systematic use of the application to facilitate faster documentation and obtaining the opinion of an experienced consultant when not on call. Finally, we think the use of the WhatsApp Messenger as an adjuvant tool could be broadened to other clinical centres to assess its viability in other skeletal and non-skeletal trauma situations., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: The issue of safety in the surgical procedure has recently been widely and openly discussed at the World Health Organization. The use of latex gloves is the current standard of protection during surgery, as they remain intact throughout the procedure. The present study was designed to evaluate the rate of glove perforation during a two-hand technique using polyester sutures in a controlled experimental study., Methods: Hypothesis was that the gloves used during a two-hand technique using polyester suture suffer punctures. We used 150 pairs of gloves during the experiment. Each investigator performed 30 tests always using double gloving. They made five surgical knots on each test over a custom-made table specifically developed for the experiment. Ten tests were done at a time with a week- interval. The Control Group (CG) has 30 pairs of intact surgical gloves. The gloves were tested to impermeability by water filling and leaking was observed at three different times. Statistics relating to the perforation rate were analyzed using the chi-square test. A P value less than 0.05 was considered statistically significant., Results: During the experiment there was no loss of gloves by drilling or inadvertent error in performing the impermeability test. No perforations were detected at any time during the impermeability test with the gloves used for sutures. Also, the CG presented no leakage of the liquid used for the test. There was no statistical difference between the groups underwent suture nor between them and the GC., Conclusion: Under the studied conditions, the authors' hypotheses could not be proved. There was no damage to the surgical gloves during the entire experiment. The authors believe that the skin abrasions observed in the ulnar side of the little finger, constant throughout the experiment, must be caused by friction. We feel there is no risk of perforation of surgical gloves during a two-hand technique using polyester suture.

Breast phantoms produced with tissue-equivalent materials are used in an attempt to simulate glandular and adipose tissues, in terms of X-ray attenuation and density. In this work, a set of breast tissue-equivalent phantoms (BTE phantoms) with semicircular shapes of different thicknesses and compositions were produced. Such phantoms may be used in the measurement of the incident air kerma (K(i)) and the mean glandular dose (D(G)) delivered to patients undergoing mammography. To characterise the materials used to produce the phantoms, a series of 17-keV X-ray attenuation coefficient measurements were performed. The carbon-nitrogen-hydrogen elemental composition and the densities of the tissue-equivalent materials were also determined and compared with values available in the literature. Linear attenuation coefficients of 0.724 and 0.923 cm(-1) were determined, respectively, for adipose and glandular tissues. Such values agree with data available in the literature. On the basis of the results obtained in this work, it is suggested that BTE phantoms are used instead of polymethyl methacrylate phantoms to select exposure parameters (kV, mAs and target/filter combination) specific for breast glandularities from 0 to 50 % in the optimisation of doses in mammography.

Objective: The purpose of this study was to evaluate the effect of thromboembolic event (TEE) on the prognosis and survival of women diagnosed with the International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical cancer undergoing treatment at the National Cancer Institute (Instituto Nacional de Câncer [INCA], Ministério da Saúde), Brazil., Methods: A total of 1020 women with FIGO stage IIIB cervical cancer (International Classification of Diseases, C53.9), who had received treatment at this institute between 2000 and 2004, were identified. Data were obtained from the hospital cancer registry at INCA. Patients were followed up from the date of their diagnosis of cervical cancer at INCA until their death or last follow-up visit. The date of TEE diagnosis was defined as the date of one of the following tests diagnosing this condition: Doppler ultrasound scan, computed tomography scan, or in 1 single case echocardiography. The Kaplan-Meyer method was used to perform long-term survival analysis., Conclusions: The presence of TEE in patients with FIGO stage IIIB cervical cancer seems to be indicative of the severity of the disease and poorer prognosis. The most important finding is that in the patients who developed TEE, this complication occurred around the time of diagnosis of progression of the disease. Disease progression may have been the triggering factor for the development of TEE.

Purpose: To evaluate the factors leading to delays in obtaining definitive diagnosis of suspicious lesions for breast cancer., Methods: A cross-sectional, observational study was carried out with 104 women attending a cancer hospital with a diagnosis or suspected diagnosis of breast cancer. A semistructured questionnaire on the patients' demographic, clinical characteristics and the use of services was applied.Variables were compared using t-Student test, Mann-Whitney test, Pearson's chi2 test or Fisher's exact test, as appropriate. In order to identify the variables associated with delays in breast cancer diagnosis, the Odds Ratio (OR) were calculated together with their respective 95% confidence intervals (95%CI) and a logistic regression model was constructed., Results: Age of patients was 54+/-12.6 years (mean+/-standard deviation). Most of the women were white (48.1%), married (63.5%), living in the city of Rio de Janeiro (57.7%) and poorly educated (60.6%). The median time between the first sign or symptom of the disease and first consultation was one month and the mean time between first consultation and confirmation of diagnosis was 6.5 months. In 51% of the women, diagnosis was late (stages II-IV). Symptomatic presentation and longer delay between symptom onset and the first evaluation and between symptom onset and the diagnosis were found to be significant factors (p<0.05) for delays in obtaining definitive diagnosis of suspicious lesions., Conclusions: The results of this study suggest that efforts must be made to reduce the time needed to get an appointment with a doctor and to confirm a diagnosis of suspicious lesions, as well as to educate physicians and the women themselves regarding the importance of breast symptoms and the value of prompt evaluation, diagnosis, and treatment.

Intraoperative radiotherapy with a single dose of electrons (ELIOT) in the conservative treatment of breast cancer is a possibility under evaluation in clinical trials. The costs of the mobile linear accelerator with a robotic arm, used in intraoperative radiotherapy, are prohibitive for poor countries. The aim of this study was to evaluate the feasibility of ELIOT in the accelerator room of the Radiotherapy Service for early breast cancer treatment. We analyzed 40 patients submitted to breast conservative surgery and ELIOT, in the accelerator room of the Radiotherapy Service at the Hospital of Pontificia Universidade Católica do Rio Grande do Sul in Brazil from January 2004 to July 2005. Patients with unifocal breast carcinoma smaller than 25 mm, aged over 45 years, who were candidates for conservative surgery were selected and a total dose of 21Gy was delivered, without further radiotherapy. In the short-term follow-up (median 18 months), six patients (15%) presented with some grade of fibrosis under the scar. One case (2.5%) of local recurrence was reported. There are no cases of contralateral carcinoma or distant metastases so far. Our data show that intraoperative radiotherapy with electrons can be safely performed in an accelerator room with a conventional machine.

The authors evaluate the consequences of incomplete necroscopic examinations wherein it was impossible to apply radiological resources to locate firearm projectiles. The study includes 8185 reports from the Instituto Médico-Legal Afrânio Peixoto in Rio de Janeiro, Brazil, representing the totality of corpses processed from January to December 2001; of these, 3122 were gunshot victims, 309 of which were buried with unremoved projectiles, being liable to future judicial reappraisal. During the same period, there were 23 exhumation requests by police authorities, 12 of them querying the existence of projectiles. The authors looked into the formal reasons assumed by the medico legal experts to conclude their reports from incomplete examinations, and suggest that gunshot necroscopic examinations should follow specific protocols, as incomplete autopsies will require further exhumations, at unnecessary additional costs.

The purpose of this research was to study the growth of the nasopharynx and adenoid development. Lateral cephalometric radiographs obtained from 320 white Brazilian subjects between 4 and 16 years of age were used. All the participants were nose breathers and none of them had previously undergone adenoidectomy. Tracings were made from the radiographs and cephalometric measurements were performed. The results showed that adenoid sagital thickness is larger in the age group 4 - 5 years and decreases progressively. There is a slight increase in the age group 10 - 11 years, but afterwards the decrease continues. However, the nasopharyngeal free airway space does not decrease in the age group 10 - 11 years, despite the increasing thickness of the adenoid. This is attributable to the downward displacement of the hard palate, resulting in an increase of the free airway space due to growth. Although the nasopharynx follows a growth pattern similar to that of the rest of the body, adenoid tissue does not. Adenoidal development seems to differ from that of other lymphatic tissues, showing a peculiar pattern that can be revealed when hypertrophy due to infections and allergies is eliminated.

The aims were to characterize the anatomical region where the lateral laryngopharyngeal protrusion occurs and to define if this protrusion is a normal or a pathological entity. This protrusion was observed on frontal contrasted radiographs as an addition image on the upper portion of the laryngopharynx. We carried out a plane-by-plane qualitative anatomical study through macroscopic and mesoscopic surgical dissection on 12 pieces and analyzed through a videofluoroscopic method on frontal incidence the pharyngeal phase of the swallowing process of 33 patients who had a lateral laryngopharyngeal protrusion. The anatomical study allowed us to identify the morphological characteristics that configure the high portion of the piriform recess as a weak anatomical point. The videofluoroscopic study allowed us to observe the laryngopharyngeal protrusion and its relation to pharyngeal repletion of the contrast medium. All kinds of the observed protrusions could be classified as "lateral laryngopharyngeal diverticula." The lateral diverticula were more frequent in older people. These lateral protrusions can be found on one or both sides, usually with a small volume, without sex or side prevalence. This formation is probably a sign of a pharyngeal transference difficulty associated with a deficient tissue resistance in the weak anatomical point of the high portion of the piriform recess.

Background: The pharyngeal phase of swallowing has received more attention than oral phase although they are presumably interdependent., Aims: 1. to evaluate, through the videofluoroscopic method, the oral phase of swallowing in order to observe the characteristics organization of the liquid bolus in healthy volunteers and the variations of this organization in exams of patient with dysphagia; 2. to establish the functional interrelation between both organization and ejection stages; 3. to verify the presence (or absence) of interference of the oral phase over the pharyngeal phase., Casuistic and Method: Videofluoroscopic assessment has been performed in patients with stroke (15), patients with Parkinson disease (15) and in health volunteers (14). All of the studied individuals were submitted to the swallowing videofluoroscopic evaluation following protocol described by Junqueira and Costa. We privileged the incidence in right profile with middle of liquid contrast (solution of barium sulfate)., Results: According to the intra-oral organization of the contrasted bolus, we could classify the oral organization as: 1. closed, 2. open, that can be subdivided in open "anterior restricted" and "open expanded", 3. prolonged, and 4. unstable. The ejection can be defined as: 1. appropriate, 2. lentify, and 3. in two times. The correlation among the oral dynamics acted by the organization and pharyngeal phases can be noticed as: 1. appropriate, 2. adapted, and 3. altered. The organization and ejection types as well as the observed correlations are shown with statistics significance., Conclusions: The closed organization type was the one characterized as normal. The "open expanded", "prolonged" and "unstable" organization type can be associated with alteration in the swallowing process. The "lentify" and "two times" ejection types also point to swallowing physiology alteration. There are functional correlation between organization and oral ejection. The oral organization has influence, not only in the quality of the oral ejection, but also, in the effective dynamics of the pharyngeal phase.

Existing methods for quantitating yeasts in beverages include time-consuming plate counts that detect only living cells and hemacytometer counts that are reliable only at very high concentrations (e.g., 10(6) to 20 X 10(6) cells per ml). The new method described here involves the use of fluorescence microscopy with the fluorescent stain aniline blue to differentiate yeasts (and other fungi) from backgrounds for easy counting and also may be used in conjunction with membrane filtration to concentrate yeasts from liquids before cell enumeration. Recoveries averaged 91.5% for beverages spiked with levels of 500 to 600,000 organisms per ml. The correlation coefficient of count to spike level was 0.996.

The proof of a chlorophyllous alga of the genus Prototheca from the blood of a tuberculous patient with brain damage is described. The pathogenetic importance of Protothecae in the field of human medicine is discussed. Although representatives of the genus Protothecae up to now are regarded as extraordinarily infrequent commensals, nevertheless occasionally their proof not only on the surface of the skin but also from the blood or the inner organs must be taken into account.

Existing methods for quantitating yeasts in clinical specimens usually rely on plate counts of sediments. A new method has been developed which uses filtration to concentrate a sample and fluorescence microscopy to facilitate counting. This method is fast and easy to perform and can be used for a wide variety of specimens including urine, mouthwash water, and vaginal fluid.