Harald Widhalm

A Proinflammatory State Is Detectable in Obese Children and Is Accompanied by Functional and Morphological Vascular Changes

Background—Obesity is generally accepted as a risk factor for premature atherosclerosis. Subclinical inflammation as quantified by blood levels of C-reactive protein (CRP) contributes to the development and progression of atherosclerosis. We hypothesized that inflammation in obese children is related to functional and early morphological vascular changes. Methods and Results—Blood levels of high sensitivity (hs) CRP, hsIL-6, the soluble intercellular adhesion molecule1 (ICAM-1), vascular cell adhesion molecule (VCAM)-1, and E-selectin were measured in 145 severely obese (body mass index [BMI], 32.2±5.8 kg/m2) and 54 lean (BMI, 18.9±3.2 kg/m2) children 12±4 years old. Flow-mediated dilation (FMD) of the brachial artery and carotid intima-media thickness (IMT) measured by high-resolution ultrasound as markers of early vascular changes were assessed in 92 (77 obese and 15 lean) and 59 (50 obese and 9 lean) children, respectively. Obese children had significantly higher levels of hsCRP, hsIL-6, and E-selectin than healthy controls (4.1±4.8 versus 0.9±1.5 mg/L, P<0.001 for hsCRP; 1.99±1.30 versus 1.42±1.01 pg/mL, P=0.05 for hsIL-6; and 78±38 versus 59±29 ng/mL, P=0.01 for E-selectin). There were no differences in the levels of ICAM-1 and VCAM-1 between groups. Obese children had lower peak FMD response (7.70±6.14 versus 11.06±3.07%, P=0.006) and increased IMT (0.37±0.04 versus 0.34±0.03 mm, P=0.03) compared with controls. Morbidly obese children (n=14, BMI 44.1±3.9 kg/m2) had highest levels of hsCRP (8.7±0.7 mg/L), hsIL-6 (3.32±1.1 pg/mL), and E-selectin (83±40 ng/mL). Conclusions—A proinflammatory state is detectable in obese children, which is accompanied by impaired vascular endothelial function and early structural changes of arteries, even in young subjects at risk. It remains to be determined whether high hsCRP in obese children predicts cardiovascular events.

Predictive value of neuromarkers supported by a set of clinical criteria in patients with mild traumatic brain injury: S100B protein and neuron-specific enolase on trial: Clinical article

OBJECT The role of the neuromarkers S100B protein and neuron-specific enolase (NSE) in minor head injury is well established. Moreover, there are sensitive decision rules available in the literature to identify clinically important brain lesions. However, it is not clear if using the biomarkers has an influence on the predictability of the decision rule. The purpose of this study was to determine if a set of preclinical and clinical parameters combined with 2 neuromarker levels could serve as reliable guidance for accurate diagnosis. METHODS Prospective evaluation of a cohort of head trauma patients with Glasgow Coma Scale scores of 13-15 was performed at an academic, Level I trauma center. Blood samples and cranial CT studies were obtained for all patients within 3 hours after injury. The hypothesis of the study was whether the combination of an increase of S100B and NSE levels in serum and other defined risk factors are associated with a pathological finding on CT. A forward stepwise logistic regression model was used. RESULTS The study included 107 head trauma patients with a mean age of 59 ± 23 years. Twenty-five patients (23.4%) had traumatic lesions on CT. Eight patients underwent craniotomy. The analysis provided a model with good overall accuracy for discriminating cases with clinically important brain injury, including the 6 variables of S100B, NSE, nausea, amnesia, vomiting, and loss of consciousness. The area under the curve (AUC) was 0.88 (0.83-0.93). The receiver operating characteristic curve plots detecting clinically important brain injury for the single variables of S100B and NSE showed an AUC of 0.63 and 0.64, respectively. Conclusions The integration of the neuromarker panel as part of a diagnostic rule including the high-risk factors of nausea, vomiting, amnesia, and loss of consciousness is safe and reliable in determining a diagnosis, pending the availability of more brain-specific neuromarkers. CLINICAL TRIAL REGISTRATION NO.: NCT00622778 (ClinicalTrials.gov).

Management and outcome of interprosthetic femoral fractures.

INTRODUCTION Interprosthetic femoral fractures following ipsilateral hip and knee arthroplasty are a rare but serious complication in clinical practice. In most cases, adequate management of these injuries might constitute a challenging problem. However, the literature provides only few data regarding the treatment and outcome of interprosthetic femoral fractures, and there are only few classifications available, which might assist in finding an appropriate treatment concept. The purpose of this study was to analyse our experience in the management of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. MATERIALS AND METHODS We reviewed the clinical and radiographic records of 23 patients (15 female and eight male, average age: 79.2 years) with an interprosthetic fracture after ipsilateral hip and knee joint replacement between 1992 and 2008. For the classification of interprosthetic femoral fractures, the fractures were divided into three types, depending on the fracture site and the adjacency to the prostheses. All patients underwent operative stabilisation, either by lateral plate fixation (n=19), by revision arthroplasty using a long stem (n=2) or by plate fixation and revision arthroplasty (n=2). RESULTS Referring to the clinical outcome, 16 patients returned to their pre-injury activity level and were satisfied with their clinical outcome. In six patients, we saw a relevant decrease of hip or knee function and severe limitations in gait and activities of daily living. We had a mean Harris Hip Score (HHS) of 78.4 points, and a mean Knee injury and Osteoarthritis Outcome Score (KOOS) of 71.8 points. Relating to the radiographic outcome, successful fracture healing was achieved in 19 of 22 patients (86%) within 6 months. Failures of reduction and fixation were noted in four (18%) of 22 patients. CONCLUSION We had a satisfactory outcome following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. Compared to the rare data in current literature, we had promising functional result and high rate of bony fusion. Regarding the complexity and challenges in many of these cases, interprosthetic fractures require an adequate analysis of the fracture aetiology and a suitable transfer into the best possible treatment concept.

Results 2 Years After Matrix-Associated Autologous Chondrocyte Transplantation Using the Novocart 3D Scaffold An Analysis of Clinical and Radiological Data

Background: A range of scaffolds is available from various manufacturers for cartilage repair through matrix-associated autologous chondrocyte transplantation (MACT), with good medium- to long-term results. Purpose: To evaluate clinical and magnetic resonance imaging (MRI) outcomes 2 years after MACT on the knee joint using the Novocart 3D scaffold based on a bilayered collagen type I sponge. Study Design: Case series; Level of evidence, 4. Methods: Of 28 initial patients, 23 were clinically and radiologically evaluated 24 months after transplantation. Indications for MACT were chondral or osteochondral lesions on the knee joint with a defect size >2 cm2, no instability, and no malalignment (axis deviation <5°). Then, MRI was performed on a 3-T scanner to assess the magnetic resonance observation of cartilage repair tissue (MOCART) and 3-dimensional (3D) MOCART scores. A variety of subjective scores (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Noyes sports activity rating scale, Tegner activity scale, and visual analog scale [VAS] for pain) were used for clinical evaluation. Results: Two years after MACT, the MRI evaluation showed a mean MOCART score of 73.2 ± 12.4 and a 3D MOCART score of 73.4 ± 9.7. Clinical results showed mean values of 69.8 ± 15.2 for the IKDC; 51.6 ± 21.2, 86.5 ± 13.9, 54.5 ± 23.6, 65.0 ± 8.0, and 91.5 ± 10.6 for the KOOS subscales (Quality of Life, Pain, Sports and Recreation, Symptoms, and Activities of Daily Living, respectively); 77.5 ± 12.7 for the Noyes scale; 4.4 ± 1.6 for the Tegner activity scale; and 1.8 ± 1.7 for the VAS, with statistically significant improvement in all scores other than KOOS-Symptoms. Conclusion: Undergoing MACT using the Novocart 3D scaffold is an applicable method to treat large focal chondral and osteochondral defects, with good short-term clinical and radiological results.

Bariatric surgery in morbidly obese adolescents: long-term follow-up

OBJECTIVE Morbid obesity is an increasingly common disease in the industrialized world and poses a great challenge to the medical community. Many obese adolescents have undergone various conservative treatment methods without adequate success so that a surgical approach became necessary. We report on 18 patients who underwent bariatric surgery as well as a long-term follow-up program. METHODS Eight patients received a laparoscopic adjustable gastric banding (LAGB). Four of these had to undergo a gastric bypass surgery (GByp) as second procedure due to insufficient weight loss. Nine patients primarily received a gastric bypass. RESULTS LAGB: Mean weight loss after 24 months was 20 ± 6.3 kg. Four of the patients showed a regain in weight leading to a mean weight loss of 9 kg compared to initial weight after 53.3 months mean in this group. These patients had to undergo an additional gastric bypass procedure and lost 31 ± 18.3 kg after 18 months. GByp: Mean weight loss in nine patients after gastric bypass (primary procedure) was 31 ± 10.2 kg after 12 months and 36 ± 30.1 kg at the end of the observation time. Sleeve: Initial weight in this patient was 232 kg with a weight loss of 38 kg after 24 months. DISCUSSION AND CONCLUSION It is remarkable that in four of eight patients who underwent LAGB had to undergo a second surgical procedure (GByp). No previous indicator, neither from a psychological nor from a medical point of view, could be detected. More long-term studies including psychological aspects seem to be necessary.

Preliminary findings on biomarker levels from extracerebral sources in patients undergoing trauma surgery: Potential implications for TBI outcome studies.

Abstract Background: Despite several experimental studies on the role of S100B and NSE in fractures, no studies on the influence of surgery on the biomarker serum levels have been performed yet. Methods: The serum levels of S100B and NSE were analysed in patients with fractures that were located in the spine (group 1, n = 35) or in the lower extremity (group 2, n = 32) pre- and post-operatively. Results: The mean S100B serum level showed a significant increase (p = 0.04) post-surgery in the patients of group 1. In patients undergoing acute surgery (< 24 hours) the mean S100B serum level was 0.23 ± 0.22 μg L–1 pre-operatively and 1.24 ± 1.38 μg L–1 post-operatively. Likewise, the mean S100B serum level significantly increased in group 2 after surgery (p < 0.0001). In this group patients undergoing acute surgery showed a mean S100B serum level of 0.23 ± 0.14 μg L–1 and 1.11 ± 0.73 μg L–1 pre- and post-operatively. Conclusion: This study demonstrates significant alterations of the biomarker S100B serum levels in patients undergoing surgery. Higher S100B serum levels were found within 24 hours and might be related to the acute fracture. The NSE serum levels were unchanged and this biomarker may offer the probability to serve as a future outcome predictor in studies with patients with traumatic brain injury and additional extracerebral injuries.

Clinical outcomes after treatment of quadriceps tendon ruptures show equal results independent of suture anchor or transosseus repair technique used – A pilot study

Biomechanical studies have shown the use of suture anchors (SA) to be superior to the traditional transosseous sutures (TS) in the repair of quadriceps tendon rupture (QTR). This study aimed to analyze and compare the functional outcomes of patients treated for quadriceps tendon ruptures using suture anchors or transosseous sutures. Patients having undergone suture anchor repair or transosseous suture repair for quadriceps tendon rupture between 2010 and 2015 at one of the two participating hospitals were included. Patients from site A underwent TS repair (TS group) while patients from site B underwent SA repair (SA group). Exclusion criteria included previous or concomitant injuries of the involved knee, penetrating injuries and pre-existing neurological conditions. Clinical outcome was assessed by subjective scores (Lysholm and Tegner Scores, International Knee Documentation Committee (IKDC) Score, Visual Analog Scale (VAS) for pain), quadriceps isokinetic strength testing, Insall-Salvati Index (ISI), and physical examination. Non-parametrical statistical analysis was conducted using the Mann-Whitney U test. Twenty-seven patients were included in the study of which 17 patients (63%) were available for follow-up (SA group: 9, TS group: 8). All patients were male with a mean age of 62.7 (SD: 8.8) and 57.9 (SD: 12.7) years for the SA group and TS group, respectively. The groups did not differ in terms of demographic characteristics. No clinically significant differences were identified between the two groups. There were no re-ruptures in either group. Treatment of quadriceps tendon rupture using suture anchors provides a clinically valid alternative treatment to the gold-standard transosseous suture repair.

Effect of daily intake of yoghurt and bread enriched with biologically active substances on blood lipids and vitamin A in adolescents and young adults.

Objective: The aim was to investigate whether the daily intake of special nutrients, enriched with supplements from natural origins, has any effect on blood parameters. Design and subjects: In this double-blind placebo-controlled clinical trial, 80 healthy subjects (mean age 26.3 years) were statistically assigned to two groups. Group I had to eat two special yoghurt and bread products a day. The other probands represented the control group (II). Setting: Plasma concentrations of blood parameters were measured at the beginning and at the end of the study, and dietary intake was calculated. Results: In group I, total cholesterol decreased. This was due to a significant drop of low-density lipoprotein-cholesterol from 106.0 to 99.0 mg/dl. A significant reduction of the apolipoprotein B and an increase of vitamin A in group I were also observed. Conclusion: Regular intake of specially fortified food influences parameters, especially lipids and lipoproteins.