ObjectivesTo determine the incidence of further procedures and serious adverse events (SAEs) requiring admission to hospital following elective surgery for base of thumb osteoarthritis (BTOA), and ...the patient factors associated with these outcomes.DesignPopulation based cohort study.SettingNational Health Service using the national Hospital Episode Statistics data set linked to mortality records over a 19-year period (01 April 1998–31 March 2017).Participants43 076 primary surgeries were followed longitudinally in secondary care until death or migration on 37 329 patients over 18 years of age.Main outcome measuresIncidence of further thumb base procedures (including revision surgery or intra-articular steroid injection) at any time postoperatively, and local wound complications and systemic events (myocardial infarction, stroke, respiratory tract infection, venous thromboembolic events, urinary tract infection or renal failure) within 30 and 90 days. To identify patient factors associated with outcome, Fine and Gray model regression analysis was used to adjust for the competing risk of mortality in addition to age, overall comorbidity and socioeconomic status.ResultsOver the 19 years, there was an increasing trend in surgeries undertaken. The rate of further thumb base procedures after any surgery was 1.39%; the lowest rates after simple trapeziectomy (1.12%), the highest rates after arthroplasty (3.84%) and arthrodesis (3.5%). When matched for age, comorbidity and socioeconomic status, those undergoing arthroplasty and arthrodesis were 2.5 times more likely to undergo a further procedure (subHR 2.51 (95% CI 1.81 to 3.48) and 2.55 (1.91 to 3.40)) than those undergoing simple trapeziectomy. Overall complication rates following surgery were 0.22% for serious local complications and 0.58% for systemic events within 90 days of surgery.ConclusionsThe number of patients proceeding to BTOA surgery has increased over the last 19 years, with a low rate of further thumb base procedures and SAEs after surgery overall registered. Arthrodesis and arthroplasty had a significantly higher revision rate.Trial registration numberNCT03573765.
Traumatic injuries cause 5.8 million deaths per year globally. Before the advent of antibiotics, sepsis was considered almost inevitable after injury. Today infection continues to be a common ...complication after traumatic injury and is associated with increases in morbidity and mortality and longer hospital stays. Research into the prevention of post-traumatic infection has predominantly focused on thoracic and abdominal injuries. In addition, because research on sepsis following musculoskeletal injuries has predominantly been on open fractures. There is a paucity of research into the prevention of soft tissue infections following traumatic injuries. This review analyses the evidence for the role of prophylactic antibiotics in the management of soft tissue injuries. Emphasis is placed on assessing the strength of the presented evidence according to the Oxford Level of Evidence scale.
Defining the optimal, evidence-based management of flexor tendon injury remains challenging. Lack of consensus on which measures to use to assess the outcome of interventions is a key issue, ...especially with regard to patient-reported outcome measures (PROMs). This systematic review defines the landscape of outcome measurement in studies on interventions for flexor tendon injuries to guide future research.
A PRISMA-compliant systematic review was conducted using bespoke search strategies applied to MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL and AMED. A protocol was developed and registered prospectively (CRD42020186780). We identified all studies describing adult patients undergoing interventions for acute hand flexor tendon injuries.
Of the 4844 studies, 114 studies met the final inclusion criteria for evaluating the outcomes of 8127 participants with 9071 injured digits. Studies included 24 randomised controlled trials, 19 cohort studies and 61 case series. Nine different PROMs were used in 24 studies (22%): three site-specific PROMs, one generic quality-of-life measure and four visual analogue scales. Clinician-reported outcome measures were used in 103 studies (96%), such as the range of motion reported in 102 studies (94%). Adverse outcomes were reported in 96 studies (89%), with the most frequently reported adverse outcomes being tendon rupture and infection. Re-operation was reported in 21 studies (19%). The most frequently reported health economic outcome measure was the length of work absence, reported in ten studies (9%).
There is variability in the use of outcome measures used to study interventions for flexor tendon injuries. An independent systematic review of the psychometric properties of the identified outcome measures and a specific multi-stakeholder consensus process may support optimal choice and standardisation for future studies.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction
There is clinical uncertainty regarding the optimal method of rehabilitation following flexor tendon repair. Many splint designs and rehabilitation regimens are reported in the ...literature; however, there is insufficient evidence to support the use of any one regimen. The aim of this study was to describe rehabilitation guidelines used in the United Kingdom (UK) following zone I/II flexor tendon repair.
Methods
Using a cross-sectional design, hand units in the UK were invited to complete a short survey and to upload their flexor tendon rehabilitation guidelines and patient information material. Approval was granted by the British Association of Hand Therapists. Data were extracted in duplicate, using a pre-piloted form, and analysed using descriptive statistics.
Results
Thirty-five hand units responded (21%), providing 52 treatment guidelines. Three splinting regimens were described, and all involved early active mobilisation: (i) long dorsal-blocking splint (DBS); (ii) short DBS; and (iii) relative motion flexion splint. Duration of full-time splint wear ranged from 4 to 6 weeks. There were variations in splint design and composition of home exercise programmes, particularly for the long DBS. Where reported, recommended return to driving ranged from 8 to 12 weeks, and return to light work activities ranged from 5 to 10 weeks.
Discussion
Treatment guidelines varied across UK hand therapy departments, suggesting that patients receive differing advice about how to protect, move and use their hand after zone I/II flexor tendon repair. The disparity in splint wear duration, home exercise frequency and prescribed functional restrictions raises potential financial and social implications for patients. Future research should explore rehabilitation burden in addition to clinical outcomes.
CONTEXT Despite decades of use and considerable research, the role of estrogen
alone in preventing chronic diseases in postmenopausal women remains uncertain. OBJECTIVE To assess the effects on major ...disease incidence rates of the most commonly
used postmenopausal hormone therapy in the United States. DESIGN, SETTING, AND PARTICIPANTS A randomized, double-blind, placebo-controlled disease prevention trial
(the estrogen-alone component of the Women's Health Initiative WHI) conducted
in 40 US clinical centers beginning in 1993. Enrolled were 10 739 postmenopausal
women, aged 50-79 years, with prior hysterectomy, including 23% of minority
race/ethnicity. INTERVENTION Women were randomly assigned to receive either 0.625 mg/d of conjugated
equine estrogen (CEE) or placebo. MAIN OUTCOME MEASURES The primary outcome was coronary heart disease (CHD) incidence (nonfatal
myocardial infarction or CHD death). Invasive breast cancer incidence was
the primary safety outcome. A global index of risks and benefits, including
these primary outcomes plus stroke, pulmonary embolism (PE), colorectal cancer,
hip fracture, and deaths from other causes, was used for summarizing overall
effects. RESULTS In February 2004, after reviewing data through November 30, 2003, the
National Institutes of Health (NIH) decided to end the intervention phase
of the trial early. Estimated hazard ratios (HRs) (95% confidence intervals
CIs) for CEE vs placebo for the major clinical outcomes available through
February 29, 2004 (average follow-up 6.8 years), were: CHD, 0.91 (0.75-1.12)
with 376 cases; breast cancer, 0.77 (0.59-1.01) with 218 cases; stroke, 1.39
(1.10-1.77) with 276 cases; PE, 1.34 (0.87-2.06) with 85 cases; colorectal
cancer, 1.08 (0.75-1.55) with 119 cases; and hip fracture, 0.61 (0.41-0.91)
with 102 cases. Corresponding results for composite outcomes were: total cardiovascular
disease, 1.12 (1.01-1.24); total cancer, 0.93 (0.81-1.07); total fractures,
0.70 (0.63-0.79); total mortality, 1.04 (0.88-1.22), and the global index,
1.01 (0.91-1.12). For the outcomes significantly affected by CEE, there was
an absolute excess risk of 12 additional strokes per 10 000 person-years
and an absolute risk reduction of 6 fewer hip fractures per 10 000 person-years.
The estimated excess risk for all monitored events in the global index was
a nonsignificant 2 events per 10 000 person-years. CONCLUSIONS The use of CEE increases the risk of stroke, decreases the risk of hip
fracture, and does not affect CHD incidence in postmenopausal women with prior
hysterectomy over an average of 6.8 years. A possible reduction in breast
cancer risk requires further investigation. The burden of incident disease
events was equivalent in the CEE and placebo groups, indicating no overall
benefit. Thus, CEE should not be recommended for chronic disease prevention
in postmenopausal women.
Background: Increased mammographic density reduces the sensitivity of screening mammography, is associated with increased breast cancer risk, and may be hormone related. We assessed the effect of ...estrogen-plus-progestin therapy on mammographic density. Methods: In a racially and ethnically diverse ancillary study of the Women's Health Initiative, we examined data from 413 postmenopausal women who had been randomly assigned to receive daily combined conjugated equine estrogens (0.625 mg) plus medroxyprogesterone acetate (i.e., progestin; 2.5 mg) (n = 202) or daily placebo (n = 211). We assessed the effect of estrogen plus progestin on measured mammographic percent density and abnormal findings over a 1-year and 2-year period. All tests of statistical significance were two-sided and were based on F tests or t tests from mixed-effects models. Results: Mean mammographic percent density increased by 6.0% at year 1, compared with baseline, in the estrogen-plus-progestin group but decreased by 0.9% in the placebo group (difference = 6.9%, 95% confidence interval CI = 5.3% to 8.5%; P<.001). The mean changes in mammographic density persisted but were attenuated slightly after 2 years, with an absolute increase of 4.9% in the estrogen-plus-progestin group and a decrease of 0.8% in the placebo group (difference = 5.7%, 95% CI = 4.3% to 7.3%; P<.001). These effects were consistent across racial/ethnic groups but were higher among women aged 70–79 years in the estrogen-plus-progestin group (mean increase at year 1 = 11.6%) than in the placebo group (mean decrease at year 1 = 0.1%) (difference of the means = 11.7%, 95% CI = 8.2% to 15.4%; P<.001, comparing across age groups). At year 1, women who were adherent to treatment in the estrogen-plus-progestin group had a mean increase in density of 7.7% (95% CI = 5.9% to 9.5%), and women in the placebo group had a mean decrease in density of 1.1% (95% CI = 0.3% to 1.9%). Use of estrogen plus progestin was associated with an increased risk of having an abnormal mammogram at year 1 (relative risk = 3.9, 95% CI = 1.5 to 10.2; P = .003), compared with placebo, that was not explained by an increase in density. Conclusions: Use of up to 2 years of estrogen plus progestin was associated with increases in mammographic density.
Cet ouvrage étudie la persistance du sacré dans la littérature après la crise religieuse qui a affecté le XXe siècle, siècle marqué par le mot célèbre de Nietzsche sur la « mort de Dieu » et par le ...silence divin à Auchwitz.
PDF
