[Translated article] Spinopelvic dissociation: Current concepts

INTRODUCTION

Spinopelvic dissociation is an uncommon injury, but, at the same time, very serious, since it can associate important complications with high morbidity and mortality. Its low frequency means that the experience of the specialists who have to deal with it is often very limited.

OBJECTIVE

To analyze the treatment indications based in classifications and surgery techniques.

METHOD

A search for scientific articles from high-impact journals was performed through international databases, such as Pubmed, Cochrane Library, Scopus, Science Direct and OVID.

CONCLUSIONS

The management of the injury we are analyzing represents a challenge. The diagnosis is carried out through a meticulous anamnesis and physical examination, supported by imaging tests, where tomography acquires special relevance. The treatment is fundamentally surgical, reserved the conservative option for a few cases. Triangular fixation is nowadays considered the treatment of choice.

Spinopelvic dissociation: Current concepts

INTRODUCTION

Spinopelvic dissociation is an uncommon injury, but, at the same time, very serious, since it can associate important complications with high morbidity and mortality. Its low frequency means that the experience of the specialists who have to deal with it is often very limited.

OBJECTIVE

To analyze the treatment indications based in classifications and surgery techniques.

METHOD

A search for scientific articles from high-impact journals was performed through international databases, such as Pubmed, Cochrane Library, Scopus, Science Direct and OVID.

CONCLUSIONS

The management of the injury we are analyzing represents a challenge. The diagnosis is carried out through a meticulous anamnesis and physical examination, supported by imaging tests, where tomography acquires special relevance. The treatment is fundamentally surgical, reserved the conservative option for a few cases. Triangular fixation is nowadays considered the treatment of choice.

[Inter-observer agreement on the Eaton-Littler classification of trapeziometacarpal joint osteoarthritis]

OBJECTIVE

To study the concordance of the radiographic classification of Eaton-Littler for the diagnosis of basal thumb joint osteoarthritis (BTJO). The null hypothesis was that the concordance was due to chance and the alternative was that the concordance was not due to chance.

MATERIAL AND METHOD

We have observed the x-rays of 46 patients with symptoms and clinical signs of BTJO. They were independently classified by five physicians: three experts in upper extremity, one in radiology and a fourth year resident of Orthopedics. We studied the concordance in the observations through the global Kappa.

DISCUSSION

The diagnosis of BTJO is based primarily on clinical exploration, radiology is a complementary method of confirmation. The classification of Eaton-Littler proposes 4 stages of the disease, with a therapeutic involvement.

CONCLUSIONS

The concordance of the radiographic classification of Eaton-Littler is moderate.

Batrachochytrium dendrobatidis in amphibians of Cameroon, including first records for caecilians

Amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) has been hypothesised to be an indigenous parasite of African amphibians. In Cameroon, however, previous surveys in one region (in the northwest) failed to detect this pathogen, despite the earliest African Bd having been recorded from a frog in eastern Cameroon, plus one recent record in the far southeast. To reconcile these contrasting results, we present survey data from 12 localities across 6 regions of Cameroon from anurans (n = 1052) and caecilians (n = 85) of ca. 108 species. Bd was detected in 124 amphibian hosts at 7 localities, including Mt. Oku, Mt. Cameroon, Mt. Manengouba and lowland localities in the centre and west of the country. None of the hosts were observed dead or dying. Infected amphibian hosts were not detected in other localities in the south and eastern rainforest belt. Infection occurred in both anurans and caecilians, making this the first reported case of infection in the latter order (Gymnophiona) of amphibians. There was no significant difference between prevalence and infection intensity in frogs and caecilians. We highlight the importance of taking into account the inhibition of diagnostic qPCR in studies on Bd, based on all Bd-positive hosts being undetected when screened without bovine serum albumin in the qPCR mix. The status of Bd as an indigenous, cosmopolitan amphibian parasite in Africa, including Cameroon, is supported by this work. Isolating and sequencing strains of Bd from Cameroon should now be a priority. Longitudinal host population monitoring will be required to determine the effects, if any, of the infection on amphibians in Cameroon.

The "Canadian model" in the international context

The focus of this commentary is on the relevance of the Canadian experience for developing countries. It highlights the growing urgency poor countries face in preserving their major human and social capital--community solidarity and family care. Developing countries face a double burden of disease--communicable and non-communicable diseases alike, with very few, and often shrinking, resources. While poorer countries will be able to learn about the essential elements of home-based care from the examples of Canada and other industrialized countries, they do need to develop their own systems based upon their economic, social, political and cultural realities. The primary health care system would seem to provide a foundation for the provision of long-term care on a sustainable and cost-effective basis. In contrast to the often-prevailing practice in developed countries, home-based care services could be integrated into the overall health and social system. Functional disability, regardless of disease aetiology or age of the care recipient, as well as the needs of family caregivers would thus become the defining elements of service eligibility. While the question remains open as to how much poor countries can learn from the experience of others, developing countries do have the opportunity to initiate a rational process where they first provide support to communities and informal caregivers and help to maintain patients in their homes and only later develop other service elements.

Signaling by toll-like receptor 2 and 4 agonists results in differential gene expression in murine macrophages

Lipopolysaccharide (LPS) derived from the periodontal pathogen Porphyromonas gingivalis has been reported to differ structurally and functionally from enterobacterial LPS. These studies demonstrate that in contrast to protein-free enterobacterial LPS, a similarly purified preparation of P. gingivalis LPS exhibited potent Toll-like receptor 2 (TLR2), rather than TLR4, agonist activity to elicit gene expression and cytokine secretion in murine macrophages and transfectants. More importantly, TLR2 stimulation by this P. gingivalis LPS preparation resulted in differential expression of a panel of genes that are normally induced in murine macrophages by Escherichia coli LPS. These data suggest that (i) P. gingivalis LPS does not signal through TLR4 and (ii) signaling through TLR2 and through TLR4 differs quantitatively and qualitatively. Our data support the hypothesis that the shared signaling pathways elicited by TLR2 and by TLR4 agonists must diverge in order to account for the distinct patterns of inflammatory gene expression.

Cutting edge: repurification of lipopolysaccharide eliminates signaling through both human and murine toll-like receptor 2

Toll-like receptor (TLR) 2 has recently been associated with cellular responses to numerous microbial products, including LPS and bacterial lipoproteins. However, many preparations of LPS contain low concentrations of highly bioactive contaminants described previously as "endotoxin protein," suggesting that these contaminants could be responsible for the TLR2-mediated signaling observed upon LPS stimulation. To test this hypothesis, commercial preparations of LPS were subjected to a modified phenol re-extraction protocol to eliminate endotoxin protein. While it did not influence the ability to stimulate cells from wild-type mice, repurification eliminated the ability of LPS to activate cells from C3H/HeJ (Lpsd) mice. Additionally, only cell lines transfected with human TLR4, but not human or murine TLR2, acquired responsiveness to both re-extracted LPS and to a protein-free, synthetic preparation of lipid A. These results suggest that neither human nor murine TLR2 plays a role in LPS signaling in the absence of contaminating endotoxin protein.

An evaluation of WHA resolution 45.5: health human resource implications

The World Health Assembly approved resolution WHA45.5 in 1992. This paper reports the findings of an evaluation of the implementation of this resolution using a survey technique. A total of 150 WHO Member States responded, for a 79% response rate. Findings suggest that the greatest strides worldwide have been made in education. While the data show that progress has been made at the country level, far more action is needed to strengthen nursing and midwifery if these cost-effective resources are to play a decisive role in improving the extent and quality of services, especially as delivered to people in the greatest need.

Cutting edge: inflammatory signaling by Borrelia burgdorferi lipoproteins is mediated by toll-like receptor 2

The agent of Lyme disease, Borrelia burgdorferi, produces membrane lipoproteins possessing potent inflammatory properties linked to disease pathology. The recent association of toll-like receptors (TLR) 2 and 4 with LPS responses prompted the examination of TLR involvement in lipoprotein signaling. The ability of human cell lines to respond to lipoproteins was correlated with the expression of TLR2. Transfection of TLR2 into cell lines conferred responsiveness to lipoproteins, lipopeptides, and sonicated B. burgdorferi, as measured by nuclear translocation of NF-kappaB and cytokine production. The physiological importance of this interaction was demonstrated by the 10-fold greater sensitivity of TLR2-transfected cells to lipoproteins than LPS. Futhermore, TLR2-dependent signaling by lipoproteins was facilitated by CD14. These data indicate that TLR2 facilitates the inflammatory events associated with Lyme arthritis. In addition, the widespread expression of lipoproteins by other bacterial species suggests that this interaction may have broad implications in microbial inflammation and pathogenesis.

Human resources for health--challenges for the 21st century

A quality health workforce is critical for the development of health systems and the delivery of health services. Although significant resources have been devoted to this area, imbalances persist in most countries. There is a growing recognition that to address current demographic, epidemiological, technological and socioeconomic changes, approaches to human resources for health development must be more comprehensive. While education and training of health personnel is a crucial element, the areas of policy development, planning and management of human resources must receive appropriate attention. Health sector reform initiatives have not included human resources development as an integral part in their processes, which has led to failures of reforms in some cases. Human resources for health must have a more prominent place on the political agenda of countries. It is apparent that to meet current and future challenges, partnerships between the many actors must be established.

Coordination of phytochrome levels in phyB mutants of Arabidopsis as revealed by apoprotein-specific monoclonal antibodies

Accumulating evidence indicates that individual members of the phytochrome family of photoreceptors have differential but interactive roles in controlling plant responses to light. To investigate possible cross-regulation of these receptors, we have identified monoclonal antibodies that specifically detect each of the five Arabidopsis phytochromes, phyA to phyE (phytochrome A holoprotein; PHYA, phytochrome A apoprotein; PHYA, phytochrome A gene; phyA, mutant allele of phytochrome A gene), on immunoblots and have used them to analyze the effects of phyA and phyB null mutations on the levels of all five family members. In phyB mutants, but not in phyA mutants, a four- to six-fold reduction in the level of phyC is observed in tissues grown either in the dark or in the light. Coordinate expression of phyB and phyC is induced in the phyB mutant background by the presence of a complementing PHYB transgene. However, in transgenic lines that overexpress phyB 15- to 20-fold, phyC is not similarly overexpressed. In these overexpressor lines, the levels of phyA, phyC, and phyD are increased two- to four-fold over normal in light-grown but not dark-grown seedlings. These observations indicate that molecular mechanisms for coordination or cross-regulation of phytochrome levels are active in Arabidopsis and have implications for the interpretation of phytochrome mutants and overexpressor lines.

A deletion in the PHYD gene of the Arabidopsis Wassilewskija ecotype defines a role for phytochrome D in red/far-red light sensing

The PHYD gene of the Wassilewskija (Ws) ecotype of Arabidopsis contains a 14-bp deletion (the phyD-1 mutation) beginning at amino acid 29 of the reading frame, resulting in translation termination at a nonsense codon 138 nucleotides downstream of the deletion end point. Immunoblot analyses showed that Ws lacks phyD but contains normal levels of phyA, phyB, and phyC. By backcrossing into the Ws and Landsberg erecta genetic backgrounds, we constructed sibling pairs of PHYD+ and phyD-1 lines and of phyB- PHYD+ and phyB- phyD- lines. Hypocotyl lengths after growth under white or red light increased sequentially in strains that were B+D+, B+D-, B-D+, and B-D-. In the Ws genetic background, an increase in petiole length, a reduction in cotyledon area and in anthocyanin accumulation in seedling stems, a diminished effect of an end-of-day pulse of far-red light on hypocotyl elongation, and a decrease in the number of rosette leaves at the onset of flowering were also seen sequentially in these lines. Thus, phyD, which is approximately 80% identical in amino acid sequence to phyB, acts in conjunction with phyB in regulating many shade avoidance responses. The existence of the apparently naturally occurring phyD-1 mutation indicates that phyD is not essential in some natural environments.

Ethical reasoning concerning the feeding of severely demented patients: an international perspective

Structured interviews were held with 149 registered nurses in seven countries in America, Asia, Australia and Europe concerning the feeding of severely demented patients who do not accept food. The most common reasons for nurses being willing to change their decision to feed or not to feed were an order from the medical head, a request from the patient's husband and/or the staff meeting. There was a connection between the willingness to feed and the ranking of ethical principles. Nurses who were most prone to feed the patient most often gave a high rank to the ethical principle of sanctity of life, while those who primarily chose not to feed the patient gave a high rank to the ethical principle of autonomy. All nurses stressed the ethical principle of beneficence.

Ethical reasoning associated with the feeding of terminally ill elderly cancer patients. An international perspective

An international nursing research study examined the ethical decision-making of "good and experienced" registered nurses in eight countries. The subjects were asked about their decision to feed or not to feed a hypothetical terminally ill, mentally alert, elderly cancer patient who refuses to eat. Cultural variations were demonstrated in the decisions as well as differences in ethical justification. The majority of nurses who would not feed appeared to use the principle of autonomy, whereas nurses who would feed the patient used beneficence as justification. Conditions under which nurses would change their decision to either feed or not feed the patient against her will included doctor's orders and lack of peer support for the decision. The majority of nurses clearly experienced a dilemma.

Feeding of severely demented patients in institutions: interviews with caregivers in Israel

In an exploratory, open-ended, and non-random study, 60 health care workers in nine long-term care institutions in Israel were questioned regarding their experiences, thoughts and feelings related to force feeding senile demented patients. The main findings were analysed according to an ethical decision-making model. Israeli care workers tended to ground their explanations in traditional Jewish sanctity of life ethics. Their actions as well as their emotional reactions seemed the logical outcome of this world view: patients were force fed and caregivers did not feel guilt for using force or accepting suffering, since they felt obliged to preserve life and thus their actions were right. They did feel ugly and upset about the situation. While most caregivers felt that force feeding was the only acceptable route in an institution, some suggested family home care where discretionary case by case ethics was seen as a viable alternative. This paper compares the Israeli interview results with those of the Swedish studies.