RESUMEN

Shoulder disorders are common in the general population : they occur in about 25 of every 1000 patients per year. A rather large majority are caused by cuff disorders. Differentiating between impingement and cuff rupture is essential to adequate treatment. Clinical tests have been developed, but their accuracy is limited. This study was performed to improve clinical accuracy by combining single tests and adding a subacromial injection. We postulated that the empty can and drop arm tests would result in higher sensitivity and specificity after subacromial injection. METHOD: We prospectively assessed 49 patients with the empty can and drop arm tests and used ultrasound to compare the individual and combined results. RESULT: The ultrasound found six cuff ruptures. Specificity improved and sensitivity decreased after subacromial injection. CONCLUSION: Only specificity improved after subacromial injection. Combining the test results led to an increase in both sensitivity and specificity without injection.

Asunto(s)

RESUMEN

Balance deteriorates with age, and may eventually lead to falling accidents which may threaten independent living. As Taekwondo contains various highly dynamic movement patterns, Taekwondo practice may sustain or improve balance. Therefore, in 24 middle-aged healthy volunteers (40-71 year) we investigated effects of age-adapted Taekwondo training of 1 h a week during 1 year on various balance parameters, such as: motor orientation ability (primary outcome measure), postural and static balance test, single leg stance, one leg hop test, and a questionnaire. Motor orientation ability significantly increased in favor of the antero-posterior direction with a difference of 0.62° toward anterior compared to pre-training measurement, when participants corrected the tilted platform rather toward the posterior direction; female gender being an independent outcome predictor. On postural balance measurements sway path improved in all 19 participants, with a median of 9.3 mm/s (range 0.71-45.86), and sway area in 15 participants with 4.2 mm(2)/s (range 17.39-1.22). Static balance improved with an average of 5.34 s for the right leg, and with almost 4 s for the left. Median single leg stance duration increased in 17 participants with 5 s (range 1-16), and in 13 participants with 8 s (range 1-18). The average one leg hop test distance increased (not statistically significant) with 9.5 cm. The questionnaire reported a better "ability to maintain balance" in 16. In conclusion, our data suggest that age-adapted Taekwondo training improves various aspects of balance control in healthy people over the age of 40.

RESUMEN

BACKGROUND: The tendency of sepsis to progress rapidly and the benefit of an early start of treatment emphasise the importance of fast risk stratification in the emergency department (ED). The aim of the present work was to validate the Mortality in Emergency Department Sepsis (MEDS) score as a predictor of 28-day mortality in ED patients with sepsis in The Netherlands, and to compare its performance to C reactive protein (CRP) and lactate. METHODS: This was a historical cohort study in a secondary and tertiary care university hospital. Patients were included if they were seen by an internist in the ED, fulfilled the clinical criteria for sepsis and were admitted to the hospital. Primary outcome was all-cause in-hospital mortality within 28 days. RESULTS: In the 6-month study period, 331 patients were included, of whom 38 (11.5%) died. Mortality varied significantly per MEDS category: ≤4 points (very low risk: 3.1%), 5-7 points (low risk: 5.3%), 8-12 points (moderate risk 17.3%), 13-15 points (high risk: 40.0%), >15 points (very high risk: 77.8%). Receiver operating characteristic (ROC) analysis showed that the MEDS score predicted 28-day mortality better than CRP (area under the curve (AUC) values of 0.81 (95% CI 0.73 to 0.88) and 0.68 (95% CI 0.58 to 0.78), respectively). Lactate was not measured in enough patients (47) for a valid evaluation, but seemed to predict mortality at least fairly (AUC 0.75, 95% CI 0.60 to 0.90). CONCLUSIONS: The MEDS score is an adequate tool for predicting mortality in patients with sepsis in a Dutch internistic ED population. CRP is less useful in this context. Lactate appears to be at least a fair predictor of mortality, but needs to be investigated more systematically in a larger population.

Asunto(s)

Asunto(s)

RESUMEN

Temozolomide has been used as a standard therapy for the treatment of newly diagnosed glioblastoma multiforme since 2005. To assess the effectiveness of temozolomide in routine clinical practice, we conducted an observational study at Maastricht University Medical Centre (MUMC). Data of patients receiving radiotherapy and temozolomide between January 2005 and January 2008 were retrieved from a clinical database (radiochemotherapy group), as were data of patients in a historical control group from the period before 2005 treated with radiotherapy only (radiotherapy group). The primary endpoint was overall survival. A total of 125 patients with GBM were selected to form the study cohort. Median survival benefit was 4 months: the median overall survival was 12 months (95% CI, 9.7-14.3) in the group with radiochemotherapy with temozolomide, versus 8 months (95% CI, 5.3-10.7) in the group with only radiotherapy. Progression-free survival was 7 months (95% CI, 5.5-8.5) in the radiochemotherapy group and 4 months (95% CI, 2.9-5.1) in the group with only radiotherapy. The two-year survival rate was 18% with radiochemotherapy with temozolomide against 4% with radiotherapy alone. Concomitant treatment with radiotherapy and temozolomide followed by adjuvant temozolomide resulted in grade III or IV haematological toxic effects in 9% of patients. The addition of temozolomide to radiotherapy in routine clinical practice for newly diagnosed glioblastoma resulted in a clinically meaningful survival benefit with minimal haematological toxicity, which confirms the experience of previous trials and justifies the continued use of temozolomide in routine clinical practice.

Asunto(s)

RESUMEN

AIM: The prevalence of obesity is rising. Because obesity is positively associated with many health related risks and negatively associated with life expectancy this is a threat to public health. Physical exercise is a well known method to lose fat mass. Due to shame of their appearance, bad general condition and social isolation, starting and continuing physical exercise tends to be problematic for obese adults. A supervised training program could be useful to overcome such negative factors. In this study we hypothesized that offering a supervised exercise program for obese adults would lead to greater benefits in body fat and total body mass reduction than a non-specific oral advice to increase their physical activity. METHODS: Thirty-four participants were randomised to a supervised exercise program group (N.=17) and a control group (N.=17). Fifteen candidates in the intervention group and 12 in the control group appeared for baseline measurements and bought an all inclusive sports pass to a health club for Euro 10, per month. The control group just received the oral advice to increase their physical activity at their convenience. The supervised exercise group received biweekly exercise sessions of 2 hours with an estimated energy expenditure of 2 500 kJ per hour. Both groups received no dietary advice. RESULTS: After 4 months the overall decrease in body mass in the intervention group was 8.0 kg (SD 6.2) and the decrease in body fat was 6.2 kg (SD 4.5). The control group lost 2.8 kg overall (SD 4.2) and the decrease in body fat was 1.7 kg (SD 3.1). Correction for differences between groups in gender and age by multiple linear regression analysis showed significantly greater loss of total body mass (P = 0.001) and fat mass (P =0.002) in the intervention group compared with the control group. CONCLUSIONS: Stimulation of physical activity alone seems to result in a slight short term body mass and fat mass reduction in obese adults who are eager to lose weight. Supervised exercise under supervision of a qualified fitness instructor leads to a larger decrease.

Asunto(s)

RESUMEN

BACKGROUND: The aim of this study was to evaluate the effects of insole configurations on plantar pressures and on walking convenience in patients with diabetic neuropathy. METHODS: Twelve different insole configurations were constructed for each of 20 patients with diabetic neuropathy. For this, different combinations of a metatarsal dome, varus and valgus wedges and arch supports with different heights were added on a fitted basic insole. Foot orthoses were evaluated while patients walked on a treadmill. Plantar pressure was measured with a Pedar Insole-system. Walking convenience was scored on a 10-point scale. FINDINGS: For the central and medial regions, plantar pressure reductions (up to 36% and 39%, respectively) were found when using a dome, standard and extra supports. The largest reductions were achieved with combination of a dome and extra support. There were no statistically significant pressure reducing effects of the insole configurations in the big toe and lateral regions, except for the effect of the combination extra support/varus wedge (21%), and for a dome (10%), respectively. The basic insole and a standard support received the best ratings for walking convenience and gradually worsened by adding extra support, a varus wedge and a dome. INTERPRETATION: A dome and the supports reduce plantar pressure in the central and medial forefoot. The combination of a dome and extra support seems to be the best choice for the construction of insoles. The results of this study are a step towards developing an evidence-based algorithm for the construction of optimal orthoses in therapeutic shoe design.

Asunto(s)

RESUMEN

The objective of this study was to determine whether the use of intramuscular botulinum toxin A (BTX-A) increases upper limb function and skills in the context of a specific therapy programme in children with hemiparetic cerebral palsy. Twenty children (nine females, 11 males) aged 4 to 16 years who were thought likely to benefit from BTX-A treatment were included. After matched pairs were made, on the basis of Zancolli grade and age, randomization took place. All patients were given structured rehabilitation (physiotherapy and occupational therapy three times a week for 6 months), and half of the patients received intramuscular BTX-A. No placebo injections were given in the control group. Participants were assessed at baseline, at 2 and 6 weeks, and at 3, 6, and 9 months after injection. The Ashworth scale, active range of motion of arm joints, the Melbourne assessment of upper limb function, the Pediatric Evaluation of Disability Inventory, and the nine-hole peg test were used for outcome measurement. Observers were blinded for treatment allocation only for scoring the Melbourne test. The children in the treatment group showed a clinically relevant increase in active dorsal flexion, and tone reduction of the wrist. For the functional outcome measures, no statistically significant differences between the groups could be demonstrated. Intramuscular BTX-A added to an intensive therapy programme reduces impairment for at least 9 months; the effect on activity level is still uncertain.

Asunto(s)

RESUMEN

BACKGROUND AND PURPOSE: Treatment of intracerebral hematoma (ICH) is controversial. An advantage of neurosurgical intervention over conservative treatment of ICH has not been established. Recent reports suggest a favorable effect of stereotactic blood clot removal after liquefaction by means of a plasminogen activator. The SICHPA trial was aimed at investigating the efficacy of this treatment. METHODS: A stereotactically placed catheter was used to instill urokinase to liquefy and drain the ICH in 6-hour intervals over 48 hours. From 1996 to 1999, 13 centers entered 71 patients into the study. Patients were randomized into a surgical group (n=36) and a nonsurgical group (n=35). Admission criteria were the following: age >45 years, spontaneous supratentorial ICH, Glasgow Eye Motor score ranging from 2 to 10, ICH volume >10 cm3, and treatment within 72 hours. The primary end point was death at 6 months. As secondary end points, ICH volume reduction and overall outcome measured by the modified Rankin scale were chosen. The trial was prematurely stopped as a result of slow patient accrual. RESULTS: Seventy patients were analyzed. Overall mortality at day 180 after stroke was 57%; this included 20 of 36 patients (56%) in the surgical group and 20 of 34 patients (59%) in the nonsurgical group. A significant ICH volume reduction was achieved by the intervention (10% to 20%, P<0.05). Logistic regression analysis indicated the possibility of efficacy for surgical treatment (odds ratio, 0.23; 95% confidence interval, 0.05 to 1.20; P=0.08). The odds ratio of mortality combined with modified Rankin scale score 5 at 180 days was also not statistically significant (odds ratio, 0.52; 95% confidence interval, 1.2 to 2.3; P=0.38). CONCLUSIONS: Stereotactic aspiration can be performed safely and in a relatively uniform manner; it leads to a modest reduction of 18 mL of hematoma reduction over 7 days when compared with control, which has a 7-mL reduction, and therefore may improve prognosis.

Asunto(s)

RESUMEN

OBJECTIVE: The aim of this study was to determine the incidence of olfactory dysfunction after mild traumatic brain injury (MTBI). Damage to the olfactory bulbs or frontal cortex has been reported in MTBI, but olfactory dysfunction after MTBI has not been studied in a prospective way before. DESIGN: Patients with first-time MTBI were included. Patients' olfactory threshold values (Hyposmia Utility Kit by Olfacto-Labs) were measured 2 weeks after the trauma. Associations between olfactory threshold values and individual symptoms and S-100B and NSE concentrations were examined, using multiple linear regression analysis, adjusting for the influence of age. RESULTS: Twenty-two per cent of 111 included patients had hyposmia and 4% had anosmia. Thresholds at 2 weeks showed no significant associations with the presence of symptoms at the ER, nor with early concentrations of S-100B or NSE. CONCLUSIONS: Although a high prevalence of olfactory dysfunction was found, no correlation was found between olfactory dysfunction and acute parameters of MTBI.

Asunto(s)

RESUMEN

OBJECTIVES: To identify parameters at first presentation after mild traumatic brain injury (MTBI) that are predictive of the severity of post-traumatic complaints (PTC) after six months. Early recognition of patients with MTBI who are at risk of developing PTC would be useful because early follow up at the outpatient clinic may help to reduce the severity of these complaints in the long run. METHODS: The presence of symptoms in the emergency room (ER) (headache, dizziness, nausea, vomiting, and neck pain) and biochemical markers (neurone specific enolase and S-100B) in serum were assessed as possible predictive variables for the severity of PTC. Outcome variables were the severity of 16 PTC six months after the trauma. RESULT: After six months, the severity of most complaints had declined to pretrauma levels but medians for headache, dizziness, and drowsiness were still increased. In a series of 79 patients, 22 (28%) reported one or more PTC after six months. After adjustment for baseline variables, an at least twofold increased severity of all PTC subgroups was reported by those patients reporting headache, dizziness, or nausea in the ER. A twofold increased severity of "cognitive" and "vegetative" PTC was also found in those with increased concentrations of biochemical serum markers at first presentation. The prevalence of full recovery after six months increased from 50% in patients with three symptoms to 78% in those with no symptoms in the ER. Inclusion of biochemical markers showed that all 10 patients with no symptoms in the ER and normal markers recovered fully. CONCLUSIONS: The presence of headache, dizziness, or nausea in the ER after MTBI is strongly associated with the severity of most PTC after six months. Identifying MTBI patients in the ER without headache, dizziness, nausea, or increased serum marker concentrations may be a promising strategy for predicting a good outcome.

Asunto(s)

RESUMEN

BACKGROUND: Outcome after mild traumatic brain injury (MTBI) is determined largely by the appearance of post-traumatic complaints (PTC). The prevalence of PTC after six months is estimated to be between 20 and 80%. Bed rest has been advocated to prevent PTC but its effectiveness has never been established. OBJECTIVE: To evaluate the effect of bed rest on the severity of PTC after MTBI. METHODS: Patients presenting with MTBI to the emergency room were randomly assigned to two intervention strategies. One group was advised not to take bed rest (NO) and the other to take full bed rest (FULL) for six days after the trauma. The primary outcome measures were severity of PTC on a visual analogue scale and physical and mental health on the medical outcomes study 36 item short form health survey (SF-36) at two weeks and three and six months after the trauma. RESULTS: Between October 1996 and July 1999, 107 (54 NO, 53 FULL) patients were enrolled. Outcome variables in both groups clearly improved between two weeks and six months. After adjustment for differences in baseline variables, most PTC tended to be somewhat more severe in the FULL group six months after the trauma, but no significant differences were found. Neither were there any significant differences in the outcome parameters between the two groups after three months. Two weeks after the trauma, most PTC in the FULL group were slightly less severe than those in the NO group, and physical subscores of the SF-36 in the FULL group were slightly better. These differences were not significant. Patients in the FULL group reported significantly less dizziness during the intervention period. CONCLUSIONS: As a means of speeding up recovery of patients with PTC after MTBI, bed rest is no more effective than no bed rest at all. Bed rest probably has some palliative effect within the first two weeks after the trauma.

Asunto(s)

RESUMEN

BACKGROUND: Although several rehabilitation programs, physical fitness programs or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy and effectiveness of these treatments. There are still persistent fears of causing re-injury, re-herniation, or instability. OBJECTIVES: The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery. SEARCH STRATEGY: We searched the MEDLINE, EMBASE and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, Issue 3. SELECTION CRITERIA: Both randomized and non-randomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included. DATA COLLECTION AND ANALYSIS: Two independent reviewers performed the inclusion of studies and two other reviewers independently performed the methodological quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results. MAIN RESULTS: Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately post-surgery, mainly because of lack of (good quality) studies. For treatments that start four to six weeks post-surgery there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs and there is strong evidence (level 1) that on long term follow up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There was also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months post-surgery are more effective in improving low back functional status as compared to physical agents, joint manipulations or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately post-surgery or later. None of the investigated treatments seem harmful with regard to re-herniation or re-operation. REVIEWER'S CONCLUSIONS: There is no evidence that patients need to have their activities restricted after first time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks post-operative) on short term for functional status and faster return to work and there is no evidence they increase the re-operation rate. It is unclear what the exact content of post-surgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately post-surgery or possibly four to six weeks later.

Asunto(s)

RESUMEN

Brain injury is classified clinically as severe, moderate or mild brain injury characteristics, including admission Glasgow coma score, duration of unconsciousness and post-traumatic amnesia and any focal neurological findings. Most traumatic brain injuries are classified as mild traumatic brain injury (MTBI). Headache, nausea and dizziness are frequent symptoms after MTBI and may continue for weeks to months after the trauma. MTBI may also be complicated by intracranial injuries. Experimental animal models and post-mortem studies have shown axonal damage and dysfunction in MTBI. This damage is mostly localized in the frontal lobes. Serum S-100 and NSE have been reported to be markers for the seventy of brain damage. In the literature, indications for radiodiagnostic evaluation following MTBI have been the subject of debate. Radiographs of the skull are used to exclude skull fractures, but are not useful for an evaluation of brain injury. Computed tomography of the brain seems to be the best way to exclude the development of relevant intracranial lesions. MTBI has a good clinical outcome, although a substantial group of patients develop post-concussional complaints (PCC). There is little information on the effectiveness of various methods suggested for reducing the frequency of PCC.

Asunto(s)

RESUMEN

Mild traumatic brain injury (MTBI) accounts for most traumatic brain injuries and is an important cause of morbidity. Recent studies in various European countries have shown that no consensus exists about management of patients with MTBI. This study describes the management of MTBI patients in various European hospitals. A short questionnaire covering the areas of interest was sent to several EFNS members in European countries. The results of the inquiry show that there is, at present, no consensus about criteria for, or management of MTBI in European hospitals.

Asunto(s)

RESUMEN

OBJECTIVES: The aim of the study was to determine whether serum concentrations of neuron-specific enolase (NSE) and S100-B in mild traumatic brain injury (MTBI) patients are higher than in serum of healthy controls. MATERIAL AND METHODS: Blood samples from 104 MTBI patients were taken shortly after the trauma for measurement of S-100B and NSE in serum. In 92 healthy persons these markers were also measured. Marker concentrations in serum of patients and controls were compared. In the patient group the relation between serum-marker concentrations and clinical symptoms and signs, that occurred shortly after the traumatic event, were evaluated. RESULTS: Median NSE concentration was only slightly higher in patients (9.8 microg/l; 10 to 90 percentile range 6.9 to 14.3 microg/ l) than in controls (9.4 microg/l; 6.3 to 13.3 microg/l). Median S-100B concentration was significantly higher in patients (0.25 microg/l; 0.00 to 0.68 microg/l) than in controls (0.02 microg/l; 0.00 to 0.13 microg/l). An association was found between S-100B concentrations and vomiting in patients. CONCLUSIONS: S-100B is a useful marker for brain damage in MTBI patients and seems to be associated with the presence of vomiting after the trauma.

Asunto(s)

RESUMEN

Chlamydia antibody testing (CAT) by micro-immunofluorescence (MIF) tests has been introduced into the fertility work-up as a screening test for tubal factor subfertility. In this study the role of C. pneumoniae antibodies, as a cause for false positive CAT results due to cross-reactivity with C. trachomatis antibodies in the MIF test, has been evaluated. In 240 subfertile women serological data were compared to laparoscopy findings. The prevalence of C. pneumoniae antibodies using enzyme-linked immunosorbent assay (ELISA) was 75% and did not differ between patients with and without tubal pathology. C. pneumoniae antibodies were found in 87% of women with a positive MIF test (> or =32), and in 66% with a negative MIF test (P < 0.0005). Using ELISA instead of MIF for the detection of C. trachomatis antibodies, C. pneumoniae antibodies were found in 87% of C. trachomatis positive women, and in 69% of C. trachomatis negative women (P < 0.0005). Patients without tubal factor subfertility but a positive MIF test showed C. pneumoniae antibodies more frequently than patients without tubal factor subfertility and a negative MIF test. Therefore it was suggested that C. pneumoniae antibodies may be the cause of false positive CAT results. Remarkably, tubal pathology was more common in patients who had antibodies to both C. trachomatis and C. pneumoniae.

Asunto(s)

RESUMEN

OBJECTIVE: To measure the incidence of traumatic head or brain injury in the catchment area of the Academic Hospital Maastricht (AZM), the Netherlands. DESIGN: Retrospective. METHOD: Data were collected about head injury patients who visited the emergency room of the AZM in 1997 by separate forms that were filled out for each patient who came to the emergency room. Data were added from admission records and radiology records. The AZM had a catchment area of approximately 231,000 people. RESULTS: The emergency room was attended by 1933 patients with traumatic head or brain injury. Head trauma without signs of brain injury was diagnosed in 1440 patients (74%) mild brain injury in 467 (24%) and moderate or severe brain injury in 26 (1%). The mean age was 30 years (range: 0-97) and 29% of all patients were below the age of 15. Two-thirds (67%) of patients were male. An X-ray of the skull was performed in 15% of the cases. In 7% of these X-rays a relevant abnormality was found. Eleven per cent of patients were admitted for observation. The incidence rate of traumatic head or brain injury in 1997 was 836/100,000 and the incidence of admission 88/100,000. The causes were a fall (43%), traffic accident (22%), violence (15%), sports injuries (7%), accidents during work (4%), or other/unknown (9%). CONCLUSION: Most patients with head or brain injury had mild injuries (99%, sole head injury or mild brain injury). Compared with other studies, the annual frequency of hospital admissions was low.

Asunto(s)

Asunto(s)

RESUMEN

The Shoulder Disability Questionnaire (SDQ) is a measure covering 16 items designed to evaluate functional status limitation in patients with shoulder disorders. The responsiveness of the SDQ was evaluated for 180 patients with soft tissue shoulder disorders, without underlying systemic disorders. These patients participated in a randomized placebo-controlled trial, in which ultrasound and electrotherapy appeared to be ineffective as adjuvants to standardized exercise therapy. At baseline and at 6-week follow-up, patients completed the SDQ and rated severity of shoulder pain and their chief complaint, while a research physiotherapist rated severity of symptoms and restriction of mobility. At the 6-week follow-up, patients also rated overall change since baseline. According to the calibrated responsiveness ratio (CRR) and the area under the receiver-operator characteristic curve (AUC) the SDQ discriminates accurately between self-rated clinically stable and improved subjects. The presented results suggest that the SDQ is as responsive as the compared outcome measures, and therefore is ready for use in clinical trials.

Asunto(s)