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A triangular configuration with three parallel cannulated screws is an established treatment for fixing transverse patellar fractures; however, the stability achieved with this approach is slightly lower than that attained with cannulated screws combined with anterior wiring. In the present study, triangular configurations were modified by partially or totally replacing the cannulated screws with headless compression screws (HCSs). Through finite element simulation involving a model of distal femoral, patellar, and proximal tibial fractures, the mechanical stability levels of the modified triangular configurations were compared with that of two cannulated screws combined with anterior wiring. Four triangular screw configurations were developed: three HCSs in a forward and backward triangular configuration, two deep cannulated screws along with one superficial HCS, and two superficial cannulated screws with one deep HCS. Also considered were two parallel cannulated screws (inserted superficially or deeply) combined with anterior wiring. The six approaches were all examined in full knee extension and 45° flexion under physiological loading. The highest stability was obtained with the three HCSs in a backward triangular configuration, as indicated by the least fragment displacement and the smallest fracture gap size. In extension and flexion, this size was smaller than that observed under the use of two deeply placed parallel cannulated screws with anterior wiring by 50.3% (1.53 vs. 0.76 mm) and 43.2% (1.48 vs. 0.84 mm), respectively. Thus, the use of three HCSs in a backward triangular configuration is recommended for the fixation of transverse patellar fractures, especially without the use of anterior wiring.

Background A minimally invasive technique with various screw configurations without open surgery is currently used for the fixation of transverse patellar fractures. Percutaneous crossing screw configuration has been reported to have a good bone union rate in patellar fractures. However, the difference in mechanical stability of the fractured patella between different screw-included angles has not been fully investigated. Hence, this study aims to compare the mechanical stability of parallel and crossing screw fixations with different screw-included angles for the fixation of transverse patellar fractures during level walking. Methods A finite element knee model containing a patella with a transverse fracture is created. Two headless compression screws with different angles (0°, 30°, 60°, and 90°) are used to fix the fracture. The loading conditions of the knee joint during level walking are used to compare the stability of the fractured patella with different fixation screw configurations. Results The results indicate that the maximum fracture gap opening distance increased with an increase in the included angle. Two parallel screws yield the smallest gap distance among all screw configurations. The maximum gap opening distances at the anterior leading edge of the fractured patella with two parallel screws and two screws having an included angle of 90° are 0.73 mm and 1.31 mm, respectively, at 15% walking cycle. Conclusions Based on these results, the superior performance of two parallel screws over crossing screw fixations in the fixation of transverse patellar fractures is established. Furthermore, the smaller the angle between the crossing screws, the better is the stability of the fractured patella.

Cam, a mechanism usually used to transform a rotary motion into desired output motion, has been commonly used in modern industry. In practice, a variety of practical methods have been discussed to improve the cam mechanism. In theory, however, the mobility of cam mechanism is seldom mathematically addressed. This paper mathematically discusses the necessary and sufficient design conditions for two kinds of form-closed cam mechanism (a cam with a translating flat-faced follower and a cam with an oscillating flat-faced follower) to be mobile. For the former cam mechanism, the relation between the design conditions and the cam mobility is derived by proving the identical cam contour enveloped by the flat faces. The result shows that the cam mechanism is mobile if and only if it satisfies the design conditions: (a) distance between the two follower flat faces is a constant value (twice base circle radius + total stroke of follower) and (b) summation of the displacement functions being 180 degrees out of phase must be the total stroke of the follower. For the later cam mechanism, the relation is derived by transforming the cam contour into a geometric layout associated with orthoptic curves. The result shows that the cam mechanism is mobile if and only if it satisfies the design conditions: (a) the flat faces are orthogonal, (b) the cycle of the displacement function has to be 180 degrees, (c) low dwell period and high dwell period are identical, (d) difference of rising and returning period has to be twice the stroke of follower, and (e) only one of the rising or falling period can be designed.

Introduction: Proximal fibula osteotomy (PFO) has been recognized as a surgical alternative for treating medial compartment osteoarthritis of the knee. Related peroneal neuropathies were concerned despite relatively low complications after PFO. In our clinical practice, a modification of the osteotomy level was thus made without mentioned neurologic deficits. However, a rare case of vascular injury was encountered. Herein we present a rare anterior tibial artery (ATA) psuedoaneurysm after this corrective osteotomy.Case presentation: A 55-year-old male visited our emergent room, presenting a painful swelling over his right antero-lateral shin 13 days post PFO. Radiological investigations showed an ATA pseudoaneurysm and which was solved with endovascular repair.Discussion: The suggested osteotomed level of PFO prone the peroneal neuropathies, which could be avoided by the modified level of osteotomy. Despite similar relief of knee pain, a rare case of vascular complication, ATA psuedoaneurysm, was encountered. Considering the course of ATA, the osteotomy should start at the posterolateral corner of the fibula and aim toward the anterior tibia.Conclusion: Although PFO was a simple surgical procedure, not free of complications. Recent surgical history along with alarming vascular symptoms should arouse clinical suspicion and timely intervention.

Background and aim The reliable method to stratify the gastric cancer risk after Helicobacter pylori eradication remains an elusive goal. Methods Mass eradication of H. pylori began in 2004 in a high-risk population. After eradication, a screening program involving first-stage serological tests (pepsinogen-I, pepsinogen-II, H. pylori immunoglobin G, and gastrin-17) and second-stage endoscopic examination was launched in 2015-2018. Index lesions included gastric cancer or extensive premalignant lesions. We evaluated the performance of the serological tests to "rule in" and "rule out" the risk based on positive and negative likelihood ratios, respectively. The methylation levels of microRNA-124a-3 in the stomach were measured to indicate genetic damage. Results Among 6512 invited subjects, 3895 (59.6%) participated. Both gastrin-17 and pepsinogen tests were normal in 3560 (91.4%) subjects; 206 (5.3%) gastrin-17 and 129 (3.3%) pepsinogen tests were abnormal. Years after eradication, the severity of gastritis had fallen greatly, and extensive premalignant lesions or gastric cancer frequently occurred in newly non-atrophic-appearing mucosa. Pepsinogen testing could moderately predict atrophic gastritis (positive likelihood ratio: 4.11 [95% confidence interval: 2.92-5.77]; negative likelihood ratio: 0.14 [0.10-0.19]). Gastrin-17 was not useful (0.66 and 1.20, respectively). However, pepsinogen testing poorly predicted the index lesions (2.04 [1.21-3.42] and 0.57 [0.34-0.95]). DNA methylation levels in the post-eradication mucosa were more discriminative for predicting index lesions (3.89 [2.32-6.54] and 0.25 [0.15-0.42]). Conclusions After eradication, pepsinogen false-negative results become more frequent because histology is improved but genetic damage may persist. Direct testing for genetic damage offers better discrimination.

BackgroundSerum pepsinogen (PG) is recommended as a screening test for premalignant gastric lesions. However, real-world evidence demonstrating its applicability and equivalence between different test brands is limited.MethodsMass screening began in 2018 in a high-risk Taiwanese population after eradication ofHelicobacter pylori, with the first stage of two PG tests (GastroPanel®, Helsinki, Finland and LZ-Test®, Tokyo, Japan) and the second stage of endoscopy. A positive test was defined as PG-I ®and PG-I ≤ 70 ng/mL and PG-I/II ratio ≤ 3 for LZ-Test®. Index lesions included atrophic gastritis and intestinal metaplasia. Test performance was evaluated based on the participation rate, positivity rate, referral rate, positive predictive value (PPV), and the detection rate.ResultsAmong 7616 eligible participants, 5117 (67.2%) received PG tests and 284 (5.6%) tested positive. Of those who tested positive, 105 (37.0%) underwent endoscopy. Overall PPVs for atrophic gastritis and intestinal metaplasia were 12.4% and 18.9%, respectively, with detection rates of 2.5 and 3.9 per 1000, respectively. Correlations of numerical measures between tests were high and the agreements of test results were substantial. The PPVs (16.3% vs. 16.3% and 23.8% vs. 21.3%,P = 1.00 and 0.71, respectively), detection rates (2.5 vs. 2.5 and 3.7 vs. 3.3 per 1000,P = 1.00 and 0.27, respectively), and the stage distributions of gastritis were all comparable, which were confirmed by multiple regression analyses.ConclusionsPG testing is effective for mass screening after eradication ofH. pylori. Tests from different manufacturers, even using different analytical methods and cutoff criteria, can perform equivalently.

Background and objectives: Vertebral compression fracture is a major health care problem worldwide due to its direct and indirect negative influence on health-related quality of life and increased health care costs. Although a percutaneous surgical intervention with balloon kyphoplasty or metal expansion, the SpineJack, along with bone cement augmentation has been shown to efficiently restore and fix the lost vertebral height, 21–30% vertebral body height loss has been reported in the literature. Furthermore, the effect of the augmentation approaches and the loss of body height on the biomechanical responses in physiological activities remains unclear. Hence, this study aimed to compare the mechanical behavior of the fractured lumbar spine with different restored body heights, augmentation approaches, and posterior fixation after kyphoplasty using the finite element method. Furthermore, different augmentation approaches with bone cement and bone cement along with the SpineJack were also considered in the simulation. Materials and Methods: A numerical lumbar model with an incomplete burst fracture at L3 was used in this study. Two different degrees of restored body height, namely complete and incomplete restorations, after kyphoplasty were investigated. Furthermore, two different augmentation approaches of the fractured vertebral body with bone cement and SpineJack along with bone cement were considered. A posterior instrument (PI) was also used in this study. Physiological loadings with 400 N + 10 Nm in four directions, namely flexion, extension, lateral bending, and axial rotation, were applied to the lumbar spine with different augmentation approaches for comparison. Results: The results indicated that both the bone cement and bone cement along with the SpineJack could support the fractured vertebral body to react similarly with an intact lumbar spine under identical loadings. When the fractured body height was incompletely restored, the peak stress in the L2–L3 disk above the fractured vertebral body increased by 154% (from 0.93 to 2.37 MPa) and 116% (from 0.18 to 0.39 MPa), respectively, in the annular ground substance and nucleus when compared with the intact one. The use of the PI could reduce the range of motion and facet joint force at the implanted levels but increase the facet joint force at the upper level of the PI. Conclusions: In the present study, complete restoration of the body height, as possible in kyphoplasty, is suggested for the management of lumbar vertebral fractures.

Posterior lumbar interbody fusion (PLIF) with a spacer and posterior instrument (PI) via minimally invasive surgery (MIS) restores intervertebral height in degenerated disks. To align with MIS, the spacer has to be shaped with a slim geometry. However, the thin spacer increases the subsidence and migration after PLIF. This study aimed to propose a new lumbar fusion approach using bone cement to achieve a larger supporting area than that achieved by the currently used poly aryl-ether-ether-ketone (PEEK) spacer and assess the feasibility of this approach using a sawbone model. Furthermore, the mechanical responses, including the range of motion (ROM) and bone stress with the bone cement spacer were compared to those noted with the PEEK spacer by finite element (FE) simulation. An FE lumbar L3-L4 model with PEEK and bone cement spacers and PI was developed. Four fixing conditions were considered: intact lumbar L3-L4 segment, lumbar L3-L4 segment with PI, PEEK spacer plus PI, and bone cement spacer plus PI. Four kinds of 10-NM moments (flexion, extension, lateral bending, and rotation) and two different bone qualities (normal and osteoporotic) were considered. The bone cement spacer yielded smaller ROMs in extension and rotation than the PEEK spacer, while the ROMs of the bone cement spacer in flexion and lateral bending were slightly greater than with the PEEK spacer. Compared with the PEEK spacer, peak contact pressure on the superior surface of L4 with the bone cement spacer in rotation decreased by 74% (from 8.68 to 2.25 MPa) and 69.1% (from 9.1 to 2.82 MPa), respectively, in the normal and osteoporotic bone. Use of bone cement as a spacer with PI is a potential approach to decrease the bone stress in lumbar fusion and warrants further research.

In first-line treatment of Helicobacter pylori, we have previously shown that the eradication frequency was 83·7% (95% CI 80·4-86·6) for triple therapy for 14 days (T14; lansoprazole 30 mg, amoxicillin 1 g, and clarithromycin 500 mg, all given twice daily), 85·9% (82·7-88·6) for concomitant therapy for 10 days (C10; lansoprazole 30 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg, all given twice daily), and 90·4% (87·6-92·6) for bismuth quadruple therapy for 10 days (BQ10; bismuth tripotassium dicitrate 300 mg four times a day, lansoprazole 30 mg twice daily, tetracycline 500 mg four times a day, and metronidazole 500 mg three times a day). In this follow-up study, we assess short-term and long-term effects of these therapies on the gut microbiota, antibiotic resistance, and metabolic parameters.This was a multicentre, open-label, randomised trial done at nine medical centres in Taiwan. Adult patients (20 years) with documented H pylori infection were randomly assigned (1:1:1, with block sizes of six) to receive T14, C10, or BQ10. We assessed long-term outcomes (reinfection frequency, changes in the gut microbiota, antibiotic resistance, and metabolic parameters) in patients with available data, excluding all protocol violators and those with unknown post-treatment H pylori status. Faecal samples were collected before treatment and 2 weeks, 2 months, and at least 1 year after eradication therapy. Amplification of the V3 and V4 hypervariable regions of the 16S rRNA was done followed by high-throughput sequencing. Susceptibility testing for faecal Escherichia coli and Klebsiella pneumoniae was done. This trial is complete and registered with ClinicalTrials.gov, NCT01906879.Between July 17, 2013, and April 20, 2016, 1620 participants were randomly assigned to the three treatment groups (540 [33%] per group). 1214 (75%) attended 1-year follow-up and are included in this analysis. Compared with baseline, alpha diversity was significantly reduced 2 weeks after T14 (p=0·0002), C10 (p0·0001), and BQ10 (p0·0001) treatment. Beta diversity was also significantly altered 2 weeks after T14 (p=0·0010), C10 (p=0·0001), and BQ10 (p=0·0001). Alpha diversity and beta diversity were restored at week 8 (p=0·14 and p=0·918, respectively) and 1 year (p=0·14 and p=0·918) after T14, but were not fully recovered at week 8 and after 1 year in patients treated with C10 (p=0·0001 and p=0·013 at week 8; p=0·019 and p=0·064 at 1 year) and BQ10 (p0·0001 and p=0·0002; p=0·001 and p=0·029). A transient increase at week 2 after T14 and C10 of the resistance rates of E coli to ampicillin-sulbactam (12% [15/127] to 66% [38/58] for T14, 7% [10/135] to 64% [28/44] for C10), cefazolin (13% [16/127] to 43% [25/58] for T14, 10% [13/135] to 41% [18/44] for C10), cefmetazole (8% [10/127] to 26% [15/58] for T14, 4% [5/135] to 18% [8/44] for C10), levofloxacin (8% [10/127] to 35% [20/58] for T14, 7% [10/135] to 32% [14/44] for C10), gentamicin (13% [19/146] to 47% [27/58] for T14, 15% [22/149] to 45% [20/44] for C10), and trimethoprim-sulfamethoxazole (33% [48/146] to 86% [50/58] for T14, 28% [42/148] to 86% [38/44] for C10; p0·05 in paired samples in the above analyses) returned to basal state at week 8 and after 1 year. Although bodyweight and body-mass index slightly increased, there were significant improvements in metabolic parameters, with a decrease in insulin resistance, triglycerides, and LDL and an increase in HDL. Overall, there was no significant change in the prevalence of metabolic syndrome at week 8 and 1 year after T14, C10, and BQ10.Eradication of H pylori infection has minimal disruption of the microbiota, no effect on antibiotic resistance of E coli, and some positive effects on metabolic parameters. Collectively, these results lend support to the long-term safety of H pylori eradication therapy.National Taiwan University Hospital and Ministry of Science and Technology of Taiwan.

BACKGROUND AND AIM The reported prevalence of Helicobacter pylori infection in Taiwan was 54.4% in 1992. An updated prevalence of H. pylori infection in asymptomatic adults is lacking in Taiwan. We aimed to assess the updated age-standardized prevalence of H. pylori infection in asymptomatic subjects and in patients with dyspepsia and to assess the accuracy of H. pylori stool antigen (HpSA) test for screening of H. pylori in Chinese population. METHODS Asymptomatic adult subjects (N = 189) were screened for H. pylori infection using HpSA, serology, and 13 C-urea breath test (13 C-UBT) in 2016-2017. Adult patients with dyspepsia (N = 145) were screened for H. pylori using 13 C-UBT, HpSA, serology, rapid urease test, and histology during 2016-2018. Two types of HpSA, including the Diagnostec HpSA ELISA Kit (HpSA ELISA) and Rapid Test Kit (HpSA Rapid), were used in this study. Sensitivity, specificity, and accuracy of the HpSA tests were calculated using the 13 C-UBT as golden standard test. RESULTS The unadjusted prevalence of H. pylori was 21.2% in asymptomatic adults and 37.9% in patients with dyspepsia (P

Tibial tubercle osteotomy (TTO) is commonly performed in cases of complicated juxta-articular trauma or revision total knee arthroplasty. However, strategies for firmly fixing the resulting osteotomy bone fragment are not sufficiently understood. This study aims to investigate the effect of the location of the gap between the fragment and the tibia and with various fixed screw configurations on TTO stability, contact force on the fragment, and bone stress by using the finite element method. A TTO model with a 1-mm gap, either above or below the fragment, was developed. Furthermore, five screw configurations, including two parallel horizontal screws placed at 20- and 30-mm intervals, two parallel downward screws, two trapezoid screws, and two divergent screws, were used. A vertically upward 1600-N force was applied on the tibial tubercle to mimic a worst-case condition. Placing the fragment close to the superior cutting plane (above the gap) yielded greater stability and less stress on the bone than did placing it close to the inferior cutting plane. The superior cutting plane of the tibia generated the largest contact force on the superior plane of the fragment for static balance under loading. Additionally, among all screw configurations, the configuration involving two parallel downward screws resulted in the highest stability but also the greatest stress on the cortical bone. The fragment obtains a solid barrier and support from the tibia immediately after surgery to against the patellar tension force when the fragment is close to the superior cutting plane of the tibia.

Background To maintain the corrected alignment after high tibial osteotomy (HTO), fixation with titanium locking plate and screws is widely used in current practice; however, screw breakage is a common complication. Thus, this study was to investigate the mechanical stability of HTO with locking plate and various screw fixations, including the length as well as the type. Methods A finite element (FE) model involving a distal femur, meniscus, and a proximal tibia with HTO fixed with a titanium locking plate and screws was created. The angle of the medial open wedge was 12°, and bone graft was not used. Two types of screws, namely conventional locking and far-cortical locking screws, with various lengths and configurations were used. At the proximal tibia, conventional locking screws with different lengths, 30 and 55 mm, were used; at the tibia shaft, different screw fixations including one-cortical, two-cortical, and far-cortical locking screws were used. Results The use of far-cortical locking screw generated the highest equivalent stress on the screws, which was four times (from 137.3 to 541 MPa) higher than that of the one-cortical screw. Also, it led to the maximum deformation of the tibia and a greater gap deformation at the osteotomy site, which was twice (from 0.222 to 0.442 mm) larger than that of the one-cortical screw. The effect of different locking screw length on tibia deformation and implant stress was minor. Conclusion Thus, far-cortical locking screws and plates increase interfragmentary movement but the screw stress is relatively high. Increasing the protection time (partial weight duration) is suggested to decrease the risk of screw breakage in HTO through fixation with titanium far-cortical locking screws and plates.

Background Two parallel cannulated screws along with an anterior wire to construct a tension band is a popular approach in transverse patellar fractures. However, the optimal screw proximity, either deep or superficial screw placements, remains controversial. Hence, a new concept of the addition of a third screw to form a triangular configuration along with the original two parallel screws was proposed in this study. Therefore, the biomechanical effect of the additional third screw on the stability of the fractured patella was investigated with finite element (FE) simulation. Methods An FE knee model including the distal femur, proximal tibia, and fractured patella (type AT/OTA 34-C) was developed in this study. Four different screw configurations, including two parallel cannulated screws with superficial (5-mm proximity) and deep (10-mm proximity) placements and two parallel superficial screws plus a third deep screw, and two parallel deep screws plus a third superficial screw, with or without the anterior wire, were considered for the simulation. Results Results indicated that the addition of a third screw increased stability by reducing the dorsal gap opening when two parallel screws were deeply placed, particularly on the fractured patella without an anterior wire. However, the third screw was of little value when two parallel screws were superficially placed. In the existence of two deep parallel screws and the anterior wire, the third screw reduced the gap opening by 23.5% (from 1.15 mm to 0.88 mm) and 53.6% (from 1.21 mm to 0.61 mm) in knee flexion 45° and full extension, respectively. Furthermore, in the absence of the anterior wire, the third screw reduced the gap opening by 73.5% (from 2 mm to 0.53 mm) and 72.2% (from 1.33 mm to 0.37 mm) in knee flexion 45° and full extension, respectively. Conclusion Based on the results, a third cannulated screw superficially placed (5-mm proximity) is recommended to increase stability and maintain contact of the fractured patella, fixed with two parallel cannulated screws deeply placed (10-mm proximity), particularly when an anterior wire was not used. Furthermore, the third screw deeply placed is not recommended in a fractured patella with two parallel superficial screws.

Background Lateral hinge fracture (LHF) is associated with nonunion and plate breakage in high tibial osteotomy (HTO). Mechanical studies investigating fixation strategies for LHFs to restore stability and avoid plate breakage are absent. This study used computer simulation to compare mechanical stabilities in HTO for different LHFs fixed with medial and bilateral locking plates. Methods A finite element knee model was created with HTO and three types of LHF, namely T1, T2, and T3 fractures, based on the Takeuchi classification. Either medial plating or bilateral plating was used to fix the HTO with LHFs. Furthermore, the significance of the locking screw at the combi hole (D-hole) of the medial TomoFix plate was evaluated. Results The osteotomy gap shortening distance increased from 0.53 to 0.76, 0.79, and 0.72 mm after T1, T2, and T3 LHFs, respectively, with medial plating only. Bilateral plating could efficiently restore stability and maintain the osteotomy gap. Furthermore, using the D-hole screw reduced the peak stress on the medial plate by 28.7% (from 495 to 353 MPa), 26.6% (from 470 to 345 MPa), and 32.6% (from 454 to 306 MPa) in T1, T2, and T3 LHFs, respectively. Conclusion Bilateral plating is a recommended strategy to restore HTO stability in LHFs. Furthermore, using a D-hole locking screw is strongly recommended to reduce the stress on the medial plate for lowering plate breakage risk.

Background & Aims We aimed to compare the efficacy of genotypic resistance–guided therapy vs empirical therapy for eradication of refractory Helicobacter pylori infection in randomized controlled trials. Methods We performed 2 multicenter, open-label trials of patients with H pylori infection (20 years or older) failed by 2 or more previous treatment regimens, from October 2012 through September 2017 in Taiwan. The patients were randomly assigned to groups given genotypic resistance–guided therapy for 14 days (n = 21 in trial 1, n = 205 in trial 2) or empirical therapy according to medication history for 14 days (n = 20 in trial 1, n = 205 in trial 2). Patients received sequential therapy containing esomeprazole and amoxicillin for the first 7 days, followed by esomeprazole and metronidazole, with levofloxacin, clarithromycin, or tetracycline (doxycycline in trial 1, tetracycline in trial 2) for another 7 days (all given twice daily) based on genotype markers of resistance determined from gastric biopsy specimens (group A) or empirical therapy according to medication history. Resistance-associated mutations in 23S ribosomal RNA or gyrase A were identified by polymerase chain reaction with direct sequencing. Eradication status was determined by 13C-urea breath test. The primary outcome was eradication rate. Results H pylori infection was eradicated in 17 of 21 (81%) patients receiving genotype resistance–guided therapy and 12 of 20 (60%) patients receiving empirical therapy (P = .181) in trial 1. This trial was terminated ahead of schedule due to the low rate of eradication in patients given doxycycline sequential therapy (15 of 26 [57.7%]). In trial 2, H pylori infection was eradicated in 160 of 205 (78%) patients receiving genotype resistance–guided therapy and 148 of 205 (72.2%) patients receiving empirical therapy (P = .170), according to intent to treat analysis. The frequencies of adverse effects and compliance did not differ significantly between groups. Conclusions Properly designed empirical therapy, based on medication history, is an acceptable alternative to genotypic resistance–guided therapy for eradication of refractory H pylori infection after consideration of accessibility, cost, and patient preference. ClinicalTrials.gov ID: NCT01725906.

Whether concomitant therapy is superior to triple therapy of various treatment lengths for the first-line treatment of H. pylori remains controversial. The objective of this study is to compare the efficacy of concomitant therapy and triple therapy given for 5–14 days. Randomized control trials (RCTs) comparing the efficacy of concomitant therapy for 5–14 days and proton pump inhibitor–amoxicillin–clarithromycin (PAC)-based triple therapy for 5–14 days in the first-line treatment of adult patients with H. pylori infection published from 1990 to January 2018 were searched from the PubMed, Cochrane Library, and Embase. Abstracts from international annual conferences were also searched. The primary and secondary outcomes were the eradication rate according to the intention-to-treat analysis and the adverse effects, respectively. Subgroup analyses were also performed according to treatment length. This study is registered with PROSPERO, number CRD42017081328. Of the 639 articles identified, 23 RCTs including 3305 patients in the concomitant therapy group and 3327 patients in the triple therapy group were eligible. Overall, concomitant therapy was superior to triple therapy [risk ratio (RR): 1.15; 95% confidence interval (CI): 1.09–1.21; p

Background Reclining wheelchair users often add one or more sitting assistive devices to their wheelchairs, but the effect of these additional sitting assistive devices on the risk of pressure ulcers has rarely been investigated. This study examined the four modes of reclining wheelchair without and with different sitting assistive devices, namely the back reclined mode, the lumbar support with back reclined mode, the femur upward with back reclined mode, and the lumbar support with femur upward with back reclined mode, in terms of their effects on human-wheelchair interface pressure. Methods This study recruited 16 healthy participants to undergo the aforementioned four modes in random order and have their human-wheelchair interface pressure measured. The initial setting of experimental reclining wheelchair backrest was pushed backward to reach a 150° recline. The data on interface pressure were collected for 5 s while the participant maintained a stable sitting position. The contact area, average pressure, and peak pressure on the back area, ischial area, and femur area were recorded and calculated. Results Among all tested modes, the lumbar support with femur upward with back reclined mode provided the most significant reduction in stress load on the ischial area (P ≤ 0.010) and shifted part of the load to the femur area (P ≤ 0.009). Conclusions This study quantified the effects of and differences between various reclining wheelchair–sitting assistive device combination modes. These findings are useful for the decision-making processes of rehabilitation physicians, wheelchair users, and manufacturers.

Background The study proposed a novel method for converting a radiographic guide into a surgical guide and evaluated its accuracy. Materials and Methods Radiographic guide was reformed with the addition of index rods for geometric conversion method (GCM). Planning implants were projected on geometric projection planes, and the implant positions were measured. The radiographic guide was converted into surgical guide using a generic bench drill machine with GCM data. Two experiments were designed to validate the GCM. (1) In vitro test: Twenty implants were placed on five edentulous dental models by using the GCM (group 1) and Stereolithography (SLA) method (group 2), respectively. The deviations of planned and placed implant were calculated, and the precision error (PE) value was calculated to evaluate the stability of the GCM and SLA. (2) In vivo test: Nine edentulous subjects were selected for clinical implant surgery with the GCM guide. Two level of the index rods of radiographic guides were prepared for surgical guides forming. The differences between the planned and actual implants were calculated in implant head, apex, and angulation. Results The in vitro test revealed no significant differences in the planned and placed angulations between groups 1 and 2 (P > .05). The PE was not significantly different between groups 1 and 2 (P > .05). The in vivo test revealed a successful treatment of the subjects, and 16 implant sites were evaluated. The results indicated that GCM guide could achieve the three-dimensional (3D) offset deviations of 1.03 ± 0.27 mm and 1.17 ± 0.24 mm at the implant head and apex, respectively, and 1.37° ± 0.21° for the 3D angulation. Conclusion The novel method for converting a radiographic guide into a surgical guide appears accurate and stable compared with SLA.

The research purposes a disk cam mechanism with a translating double oblique flat-faced follower and demonstrates how to design such a cam mechanism. The modified follower consists of a circular arc portion tangentially connected to two oblique flat-faced portions. Such geometrical arrangements effectively reduce moment arm about the center of gravity and decrease the overturning moment caused by contact forces between the cam and the follower. This design also increases the overturning moment generated by frictions at the cam–follower interface. However, the increment is much smaller than the reduced amount of the overturning moment. Numerical examples are provided to illustrate the simulated results. The obtained results are further compared with those of the disk cam mechanism with a flat-faced follower. The results indicate that the overturning moment of the novel follower will have a 45.86% reduction during the rising period and a 73.2% reduction during the falling period. While the maximum overturning moment caused by frictions for the novel follower is larger by 8.3% during the high dwell period, the increment is much smaller than the reduction of overturning moment caused by contact forces. The application of this follower can greatly be useful in avoiding follower jamming.

Prolonged static sitting in wheelchairs increases the risk of pressure ulcers. This exploratory study proposed three dynamic sitting techniques in order to reduce the risk of developing pressure ulcer during wheelchair sitting, namely lumbar prominent dynamic sitting, femur upward dynamic sitting, and lumbar prominent with femur upward dynamic sitting. The purpose of this study was to analyze the biomechanical effects of these three techniques on interface pressure. 15 able-bodied people were recruited as subjects to compare the aforementioned sitting techniques in a random order. All parameters, including dynamic contact area, dynamic average pressure, and dynamic peak pressure on backrest and seat were measured and compared. In result, when compared with lumbar prominent dynamic sitting, femur upward dynamic sitting and lumbar prominent with femur upward dynamic sitting appeared to yield significantly lower dynamic average and peak pressure on the back part of seat, and significantly higher dynamic average and peak pressure on the front part of seat. This study can serve as a reference point for clinical physicians or wheelchair users to identify a suitable dynamic sitting technique.

Introduction Elastic stable intramedullary nailing (ESIN) is a treatment strategy for the management of diaphyseal long-bone fractures in adolescents and children, but few studies have investigated the mechanical stability of tibial diaphyseal fractures treated with various degrees of prebending of the elastic nails. Therefore, the aim of this study was to compare the mechanical stability, including the gap deformation and nail dropping, of a tibia fracture with various fracture sites and fixed with various degrees of prebending of the elastic nails by the finite element method. Furthermore, the contribution of end caps to stability was taken into consideration in the simulation. Methods A tibia model was developed with a transverse fracture at the proximal, middle and distal parts of the diaphysis, and fixed with three degrees of prebending of elastic nails, including those equal to, two times and three times the diameter of the intramedullary canal. The outer diameter of the nail used in the computation was 3.5 mm, and the fractured tibia was fixed with two elastic double C-type nails. Furthermore, the proximal end of each nail was set to free or being tied to the surrounding bone by a constraint equation to simulate with or without using end caps. Results The results indicated that using end caps can prevent the fracture gap from collapsing by stopping the ends of the nails from dropping back in all prebending conditions and fracture patterns, and increasing the prebending of the nails to a degree three times the diameter of the canal reduced the gap shortening and the dropping distance of the nail end in those without using end caps under axial compression and bending. Insufficient prebending of the nails and not using end caps caused the gap to collapse and the nail to drop back at the entry point under loading. Conclusions Using end caps or increasing the prebending of the nails to three times the diameter of the canal is suggested to stop the nail from dropping back and thus produce a more stable structure, with less gap deformation, in the management of a simulated tibial diapyhseal fracture by using titanium elastic nails with a double C-shape.

This study investigated the biomechanical response of porous cages and lumbar spine segments immediately after surgery and after bone fusion, in addition to the long-term effects of various posterior lumbar interbody fusion (PLIF) techniques, by using the finite element method. Lumbar L3-L4 models based on three PLIF techniques (a single cage at the center of the intervertebral space, a single cage half-anterior to the intervertebral space, and two cages bilateral to the intervertebral space) with and without bone ingrowth were used to determine the biomechanical response of porous cages and lumbar segments instrumented with porous titanium cages (cage porosity=50%, pore diameter=1mm). The results indicated that bone fusion enhanced the stability of the lumbar segments with porous cages without any posterior instrumentation and reduced the peak von Mises stress in the cortical bones and porous cages. Two cages placed bilateral to the intervertebral space achieved the highest structural stability in the lumbar segment and lowest von Mises stress in the cages under both bone fusion conditions. Under identical loading (2-Nm), the range of motion in the single cage at the center of the intervertebral space with bone fusion decreased by 11% (from 1.18? to 1.05?) during flexion and by 66.5% (from 4.46? to 1.5?) during extension in the single cage half-anterior to the intervertebral space with bone fusion compared with no-fusion models. Thus, two porous titanium cages with 50% porosity can achieve high stability of a lumbar segment with PLIF. If only one cage is available, placing the cage half-anterior to the intervertebral space is recommended for managing degenerated lumbar segments. A numerical model containing porous cages and a lumbar segment was developed.The bone tissue ingrowth into the pores of the cage is considered.Bone fusion enhances the stability of the lumbar segment with a porous cage.Bone fusion also reduces the peak von Mises stress in the cortical bone and porous cage.

Germ theory of disease and Koch's postulates has been governing our understanding of the role of microbes in human health since 19th century. The discovery of Helicobacter pylori (H. pylori) and H. pylori associated diseases has typically represented the concept and framework of Koch's postulates. Eradication of H. pylori to prevent peptic ulcers recurrence and gastric cancer is the triumph of this microbiology paradigm. Advances of next generation sequencing provide great insight into the unculturable microbes and show trillions of microbes have evolved with human beings. Research into the microbiome-the microbial communities (microbiota) and the host environment that they inhabit-has changed our understanding about microbes in human health and disease. The gut microbiota, the largest reservoir of the microbiome in human, plays a critical role in our catabolic-metabolism and immunity. This review will show the changes of the view of microbes on human health. We will briefly discuss dysbiosis, the disruption of symbiotic relationship between the host and microbiota, and the associated diseases. This leads to an idea to manipulate the microbiota, either by restoring missing functions or by eliminating harmful functions, to prevent or treat a variety of diseases. Current evidences of two common germ therapies, fecal microbiota transplantation and probiotics, in treating diseases will be reviewed.

Introduction To date, the effects of various screw configurations on the stability of tibial tubercle osteotomy (TTO) are not completely understood. Hence, the first aim of this study is to evaluate the stability of TTO under various screw configurations. The second aim is to evaluate the internal stresses in the bone and the contact forces on the bone fragment that are developed by the tibia and screws in response to the applied load after the equilibrant is revealed. Methods To calculate the biomechanical responses of the bone and screw under loading, finite element (FE) method was used in this study. Six types of screw configurations were studied in the simulation: two parallel horizontal screws placed at a 20 mm interval, two parallel horizontal screws placed at a 30 mm interval, two parallel upward screws, two parallel downward screws, two trapezoid screws, and two divergent screws. The displacement of the bone fragment, contact forces on the fragment, and the internal stress in the bone were used as indices for comparison. Results Among all configurations, the configuration of two parallel downward screws yielded the highest stability with the lowest fragment displacement and gap opening. Although the maximum displacement of the TTO with the configuration of two parallel horizontal screws was slightly higher than that of the downward configuration, the difference was only 0.2 mm. The configuration of two upward screws resulted in the highest fragment displacement and gap deformation between the fragment and tibia. The stress of the osteotomized bone fragment was highest with the configuration of two upward screws. Conclusion Based on the present model, the current configuration of two parallel horizontal screws is recommended for TTO. If this is inappropriate in a specific clinical scenario, then the downward screw configuration may be used as an alternative. By contrast, the configuration of two parallel upward screws is least suggested for the fixation of TTO.

Background Colorectal cancer remains a considerable challenge in healthcare nowadays. Most patients’ disease develops via the adenoma–carcinoma sequence; colonoscopy with polypectomy effectively reduces both mortality and incidence by removing precancerous adenomas. Previous studies showed that polypectomy without electrocautery (cold snaring polypectomy) is a safe and time-saving procedure to manage polyps

SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents. (DOC 120 kb)

Carbon dioxide (CO2) insufflation during colonoscopy can significantly decrease abdominal pain and bloating after the procedure, but its impact on the frequency and duration of toilet use remains unknown. The aim of this study was to assess the impact of CO2 insufflation on toilet use after screening colonoscopy.From 138 average-risk individuals who underwent screening colonoscopy during March to August 2013, 120 were enrolled and randomized to receive either CO2 or air insufflation at colonoscopy. Both the colonoscopist and participant were blinded to the type of gas used. Abdominal pain and distension were assessed using a visual analog scoring system. The frequency and duration of toilet visits during a 2-hour postcolonoscopy period were recorded using a radiofrequency identification system.Baseline characteristics were similar in both groups in terms of age, sex, and procedure time. In the 2 hours after colonoscopy, 50 participants (83 %) in the air group and 18 participants (30 %) in the CO2 group (P 0.001) used the toilet at least once. The mean (± SD) duration of each toilet visit was 5.93 ± 4.65 minutes in the air group and 1.53 ± 2.84 minutes in the CO2 group (P 0.001). The abdominal discomfort score was lower in the CO2 group than in the air group both at the end of the colonoscopy (P 0.001) and 2 hours later (P 0.001).Insufflation with CO2 can significantly reduce abdominal discomfort and toilet use after colonoscopy. Use of this technique may help reduce patient burden and allow more efficient use of space in the endoscopy unit.

Purpose: Tibial tubercle osteotomy (TTO) is a surgical technique used in the management of severe fractures of the knee joint and revision total knee arthroplasty. Limited research discusses the performance of the osteotomy and fixation of the TTO with screws. Therefore, this study investigated the effects of fragment shape and screw configuration on the mechanical behavior in the fixation of the TTO using the finite element (FE) method. Methods: FE TTO models with three fragment shapes and three screw configurations were developed. The three fragment shapes were a step cut, bevel cut, and straight cut. The screw configurations were two parallel horizontal and downward screws and two trapezoidal screws. A 1654-N upward tension force was applied on the tibia tubercle, and the distal end of the tibia was completely fixed. Results: The results indicated that the step cut resulted in higher stability than the bevel and straight cut, but the stress was higher as well. Among the screw configurations, two parallel downward screws resulted in the highest stability, given the same fragment shape. In the horizontal configuration, the step cut tibia developed the largest contact force to achieve stability of the bone fragment under loading. Conclusion: The fragment shape with a step cut and fixation with two parallel horizontal or downward screws are suggested for TTO, while the trapezoidal screw configuration is not suggested. Furthermore, the downward screw configuration is a suitable strategy to reduce bone stress.

Prolonged static sitting in a wheelchair is associated with an increased risk of lower back pain. The wheelchair seating system is a key factor of this risk because it affects spinal loading in the sitting position. In this study, 7 dynamic sitting strategies (DSSs) are examined: lumbar prominent dynamic sitting (LPDS), back reclined dynamic sitting (BRDS), femur upward dynamic sitting (FUDS), lumbar prominent with back reclined dynamic sitting (LBDS), lumbar prominent with femur upward dynamic sitting (LFDS), back reclined with femur upward dynamic sitting (BFDS), and lumbar prominent with back reclined with femur upward dynamic sitting (LBFDS). The objective of this study was to analyze the biomechanical effects of these sitting strategies on lumbar-pelvic angles. Twenty able-bodied participants were recruited for the study. All participants performed LPDS, BRDS, FUDS, LBDS, LFDS, BFDS, and LBFDS in a random order. All lumbar-pelvic angle parameters, including the static lumbar angle, static pelvic angle, lumbar range of motion, and pelvic range of motion were measured and compared. Results show that LBDS and LBFDS enabled the most beneficial lumbar movements, although the difference between the 2 strategies was nonsignificant. BRDS and BFDS enabled the most beneficial pelvic movements, although the difference between the 2 strategies was nonsignificant. Among all the upright DSSs, LPDS and LFDS enabled the most beneficial lumbar and pelvic movements, although no significant difference was observed between these 2 strategies. We identified the effects and differences among 7 DSSs on lumbar-pelvic angles. Wheelchair users can choose the most suitable DSS that meets their needs. These findings may serve as a reference for practicing physicians or wheelchair users to choose an appropriate dynamic wheelchair seating system. ISRCTN12389808 , 18th November 2016, retrospectively registered.

Fracture impaction is a surgical technique used to support the fractured humerus with locking plate or intramedullary nail when treating proximal humeral fractures. However, few studies have investigated the mechanical difference between fracture impaction with locking plate and with intramedullary nail. The mechanism of fracture impaction to increase stability is still unclear. The aim of this study was to use numerical methods to compare the biomechanical effect of treating proximal humeral fracture. Six different humerus models, including intact and fractured humeri with various fixation patterns were used in this study. Fracture impaction was simulated by moving the distal fragment of the humeral shift upwards directly until touching the inferior surface of the proximal fragment. We also considered both poor- and normal-quality bone in the simulation. Results confirmed that fracture impaction increases fracture stabilityand decreases peak stress in both implant and bone. Also, fracture impaction and plating with medial shift of the humeral shaft provides the highest stability. The metallic implant shared loading with the bone in the impacted models, while implants sustained all the loading alone in the nonimpacted models. Based on the results, the technique of fracture impaction is suggested for both nail and plate to reduce stresses on bone and implants and to increase structural stability. Furthermore, impaction with medial shift of the humeral shaft with plate is found to achieve the highest stability when treating proximal humeral fractures.

The study proposed a novel method for converting a radiographic guide into a surgical guide and evaluated its accuracy.Radiographic guide was reformed with the addition of index rods for geometric conversion method (GCM). Planning implants were projected on geometric projection planes, and the implant positions were measured. The radiographic guide was converted into surgical guide using a generic bench drill machine with GCM data. Two experiments were designed to validate the GCM. (1) In vitro test: Twenty implants were placed on five edentulous dental models by using the GCM (group 1) and Stereolithography (SLA) method (group 2), respectively. The deviations of planned and placed implant were calculated, and the precision error (PE) value was calculated to evaluate the stability of the GCM and SLA. (2) In vivo test: Nine edentulous subjects were selected for clinical implant surgery with the GCM guide. Two level of the index rods of radiographic guides were prepared for surgical guides forming. The differences between the planned and actual implants were calculated in implant head, apex, and angulation.The in vitro test revealed no significant differences in the planned and placed angulations between groups 1 and 2 (P.05). The PE was not significantly different between groups 1 and 2 (P.05). The in vivo test revealed a successful treatment of the subjects, and 16 implant sites were evaluated. The results indicated that GCM guide could achieve the three-dimensional (3D) offset deviations of 1.03 ± 0.27 mm and 1.17 ± 0.24 mm at the implant head and apex, respectively, and 1.37° ± 0.21° for the 3D angulation.The novel method for converting a radiographic guide into a surgical guide appears accurate and stable compared with SLA.