Karim Z. Masrouha

Effects of sildenafil in Nω-nitro-L-arginine methyl ester-induced intrauterine growth restriction in a rat model.

OBJECTIVE To assess the effect of sildenafil citrate in a rat model of Nω-nitro-l-arginine methyl ester (L-NAME)-induced intrauterine growth restriction (IUGR). STUDY DESIGN An in vivo experimental study was conducted where 40 pregnant Sprague-Dawley rats were randomly assigned to receive either: (1) control, (2) L-NAME 50 mg/kg/d by gavage (days 14 to 19), (3) L-NAME and sildenafil 15 mg/kg/d by gavage, or (4) sildenafil (days 14 to 21). On day 21, a hysterotomy was performed and all fetuses (live and dead) were counted, examined, and weighed. The primary outcome measure was the difference in pup birth weight. RESULTS The median number of live pups per dam was 11.5 (range: 1 to 15), 13.5 (2 to 17), 13.5 (7 to 16), and 11.5 (4 to 17) in controls, L-NAME, sildenafil, and combined drug groups, respectively (p = 0.02). Rats treated with L-NAME had a significantly higher number of stillbirths compared with control (p = 0.013) and sildenafil (p = 0.008) groups. L-NAME reduced pup birth weight compared with controls (4.53 ± 1.49 versus 5.65 ± 1.63 g, p < 0.001); this effect was more pronounced in the L-NAME and sildenafil groups (3.37 ± 1.25 g, p < 0.001). CONCLUSION Our data indicate that sildenafil citrate does not ameliorate L-NAME-induced IUGR, and in the doses utilized in this study might even have a synergistic negative effect on pup birth weight.

The impact of zoledronic acid on regenerate and native bone after consolidation and removal of the external fixator: An animal model study

We investigated the role of zoledronic acid on the regenerate and native bone after consolidation and removal of the external fixator in a rabbit model of distraction osteogenesis using 28 New Zealand white rabbits. The rabbits were randomly distributed into two groups. The first group received three doses of zoledronic acid (ZA) 0.1 mg/kg subcutaneously at weekly intervals while the second group received injections of sterile saline. Distraction started on day 7 at a rate of 0.8 mm/day for 12 days. At week 3 the average lengthening, regenerate density, and regenerate continuity were comparable between the two groups. At week 11 the regenerate in the treated group had a significant increase in Bone Mineral Density (BMD) and Bone Mineral Content (BMC) compared to the placebo group. On axial compression, the regenerate showed an increase in the peak load and a higher modulus of elasticity in the treated group. At 6 months, radiographs demonstrated signs of osteopenia of the proximal metaphysis in the control group, and failure of new bone formation around the pin sites in the treated group. BMC and BMD value differences between the two groups were not statistically significant. Histologically, there was persistence of more bone trabeculae in the medullary canal of the regenerate with the persistence of the pin-holes in the treated group. Mechanically, the regenerates in the treated group remain stronger in resisting the axial compression. The proximal fragment in the treated group exhibited a statistically significant decrease in the peak load, toughness and efail %. In conclusion, bisphosphonate-treated rabbits have a stronger regenerate during distraction, and directly after removal of the fixator. They do not develop disuse osteopenia in their lengthened tibia. This treatment may shorten the time in the external fixator and prevent fragility fractures in the treated extremity. However, its long-term safety has not yet been established.

The Association of Anemia and Its Severity with Cardiac Outcomes and Mortality After Total Knee Arthroplasty in Noncardiac Patients

BACKGROUND The purpose of this study is to assess whether an association exists between preoperative anemia and postoperative cardiac events or death in patients undergoing unilateral primary total knee arthroplasty (TKA) with no prior cardiac history. METHODS Data from the 2008-2012 American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patients aged ≥18 years undergoing unilateral primary TKA were included. We divided the patients into 4 groups: no anemia, any anemia, mild anemia, and moderate-severe anemia. Associations between anemia and different characteristics as well as cardiac outcomes and death were studied, after adjusting for all potential confounders. RESULTS In the nonanemic group, the occurrence of myocardial infarction, cardiac arrest, and death were 61 of 34,661 (0.18%), 23 of 34,661 (0.07%), and 30 of 34,661 (0.09%), respectively. The numbers in the anemia group were 23 of 6673 (0.34%), 9 of 6673 (0.13%), and 14 of 6673 (0.21%). These were not statistically different. The anemic group had higher odds for respiratory and renal morbidities and for receiving transfusions. CONCLUSION We found no association between preoperative anemia or its severity and myocardial infarction, cardiac arrest, or death up to 30 days postoperatively. This could potentially lower the bar for safe preoperative hematocrit levels for elective TKA, theoretically increasing the percentage of anemic patients undergoing the procedure. This, however, is at the expense of potential respiratory and renal insults.

Reliability and validity of an adapted Arabic version of the Scoliosis Research Society-22r Questionnaire.

Study Design. Cross-sectional validation and reliability assessment study of Arabic version of Scoliosis Research Society-22 (SRS-22r) Questionnaire. Objective. To develop and validate the Arabic version of the SRS-22r questionnaire. Summary of Background Data. The diagnosis and treatment of adolescent idiopathic scoliosis may influence patient quality of life. SRS-22r is an internationally validated questionnaire used to assess function/activity, pain, self-image, and mental health of patients with scoliosis. It has been translated into several languages but not into Arabic language. Therefore, a valid health-related quality-of-life outcome questionnaire for patients with spinal deformity is still lacking in Arabic language. Methods. The English version of SRS-22r questionnaire was translated, back-translated, and culturally adapted to Arabic language. Then, 81 patients with idiopathic adolescent scoliosis were allocated randomly into either the reliability testing group (group 1) or the validity testing group (group 2). Group 1 patients completed Arabic version of SRS-22r questionnaire twice with 1-week interval in-between. Cronbach &agr; and intraclass correlation coefficient were measured to determine internal consistency and temporal reliability. Group 2 patients completed the Arabic version of SRS-22r questionnaire and the previously validated Arabic version of 36-Item Short Form Health Survey (Short Form-36) questionnaire concurrently, and Pearson correlation coefficient was obtained to assess validity. Results. Content analysis, internal consistency reliability, test/retest reproducibility (intraclass correlation coefficient range: 0.82–0.90), and test of concurrent validity showed satisfactory results. Function/activity and satisfaction with management domains had a lower Cronbach &agr; (0.58 and 0.44, respectively, vs. 0.71–0.85 range for others). Self-image/appearance and satisfaction with management had a lower correlation with domains of the 36-Item Short Form Health Survey. Conclusion. An Arabic version of the SRS-22r questionnaire has been developed and validated. This questionnaire will aid health care workers and researchers in evaluation of patient perception of the deformity, satisfaction with treatment, and quality of life in Arabic-speaking populations. Level of Evidence: 3

Preoperative Pneumonia and Postoperative Venous Thrombosis: A Cohort Study of 427,656 Patients Undergoing Major General Surgery

BackgroundThe literature is sparse regarding the association between pneumonia and venous thrombosis in surgical patients. The aim of this study was to investigate the risk of postoperative venous thrombosis in patients who fit the criteria for preoperative pneumonia using data from the ongoing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database while adjusting for potential confounders.MethodsThis is a cohort study using data from the ACS NSQIP database participating sites from 2008 (211 sites) and 2009 (237 sites). 427,656 patients undergoing major general surgery were included. The 30-day risk of postoperative venous thrombosis including deep vein thrombosis (DVT) and pulmonary embolism (PE) was evaluated in patients with preoperative pneumonia diagnosed before undergoing major general surgery.ResultsPatients with preoperative pneumonia had a higher incidence of both 30-day DVT and PE than patients without preoperative pneumonia. After adjusting for all potential confounders, the effect estimates for the association between preoperative pneumonia and venous thrombosis were DVT, OR: 1.67 (95% CI 1.32–2.11) and PE, OR: 2.18 (95% CI 1.48–3.22).ConclusionsA large, multicenter database of surgical patients showed that preoperative pneumonia may increase risk for developing venous thrombosis. This adds to our understanding of risk factors for venous thrombosis and suggests a potential benefit of diagnosing preoperative pneumonia in patients undergoing major general surgery.

Late-onset pneumomediastinum in dermatomyositis

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Back pain: A puzzle in children.

Back pain in children is underdiagnosed and increases incidence in adolescence. A systematic approach can diagnose the most common causes: trauma, structural deformities, inflammatory diseases, infection and malignancy.

Retrograde Percutaneous Drilling for Osteochondritis Dissecans of the Head of the Talus: Case Report and Review of the Literature

Osteochondral lesions of the talus might be a more common cause of pain than previously recognized, especially among those involved in athletic activities. However, the location of an osteochondral lesion on the talar head is much less common than such lesions localized to the dome of the talus and can pose diagnostic difficulties. We present the case of a 14-year-old soccer player who complained of longstanding pain in his left foot. After unsuccessful conservative treatment consisting of rest and bracing, he was ultimately treated with retrograde percutaneous drilling of the talar head performed by a medial approach. This was followed by casting and non-weightbearing for 6 weeks, after which physical therapy was undertaken. He was able to return to full activity and remained asymptomatic during a 5-year observation period. Although rare, osteochondritis dissecans of the talar head should be considered in young athletes with persistent foot pain that is unresponsive to reasonable therapy.

Bilateral Achilles Tendon Ruptures Associated With Ciprofloxacin Use in the Setting of Minimal Change Disease: Case Report and Review of the Literature

Fluoroquinolones are widely used antibiotics; however, numerous side effects have been reported in published studies, including a spectrum of tendinopathies, affecting numerous anatomic sites. Several risk factors have been identified, including advanced age (>60 years), corticosteroid use, renal failure or dialysis, female sex, and nonobesity. We present the case of an elderly male with minimal change disease treated with glucocorticoids and acute kidney injury, who sustained spontaneous nontraumatic bilateral Achilles tendon tears 4 days after initiating ciprofloxacin.

Comparison of Early Adverse Events After Operative Treatment of Bimalleolar and Trimalleolar Fractures Versus Pilon Fractures

Abstract Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high‐energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30‐day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m2, and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures. &NA; Level of Clinical Evidence: 2