Efficacy and Tolerability of a Fixed Combination of Perindopril/Amlodipine/Indapamide in Patients with Essential Hypertension: Pilot Study / Efikasnost I Tolerabilnost Fiksne Kombinacije Perindopril/Amlodipin/Indapimida Kod Pacijenata Sa Esencijalnom Hipertenzijom: Pilot Studija

Hypertension is the major risk factor in Serbia and worldwide for the morbidity and mortality from cardiovascular and cerebrovascular diseases. A majority of patients need two or more antihypertensive drugs to adequately control blood pressure.

Our study group consisted of 12 patients with uncontrolled essential hypertension, without comorbidities, divided in two groups and followed for 12 weeks. The first group was treated with a single-pill of fixed-combination Perindopril 5 mg/Indapamide 1.25 mg and an additional tablet of Amlodipine 5 mg. The second group received a single-pill fixed-combination of Perindopril 5 mg/Indapamide 1.25 mg/Amlodipine 5 mg. Our research showed significant decreases in systolic (p=0,05) and diastolic (p<0,05) blood pressure in both groups after 12 weeks of treatment. The study also showed a higher percentage of patients who achieved the targeted blood pressure (< 140/90 mmHg) on the single-pill triple combination drug (69.7%) in comparison with the other group (50%). No adverse effects were recorded in both groups.

Our results revealed significant efficacy and tolerability of a single-pill triple-fixed combination Perindopril/Amlodipine/ Indapamide in patients with uncontrolled essential hypertension without comorbidities.

Aging of skeletal muscle fibers

Aging has become an important topic for scientific research because life expectancy and the number of men and women in older age groups have increased dramatically in the last century. This is true in most countries of the world including the Republic of Korea and the United States. From a rehabilitation perspective, the most important associated issue is a progressive decline in functional capacity and independence. Sarcopenia is partly responsible for this decline. Many changes underlying the loss of muscle mass and force-generating capacity of skeletal muscle can be understood at the cellular and molecular levels. Muscle size and architecture are both altered with advanced adult age. Further, changes in myofibers include impairments in several physiological domains including muscle fiber activation, excitation-contraction coupling, actin-myosin cross-bridge interaction, energy production, and repair and regeneration. A thorough understanding of these alterations can lead to the design of improved preventative and rehabilitative interventions, such as personalized exercise training programs.

Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation

OBJECTIVE

To report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation.

DESIGN

Retrospective chart review.

SETTING

An inpatient neurosurgery unit and outpatient physical medicine and rehabilitation clinics.

PARTICIPANTS

Fifty-seven patients with refractory spasticity who underwent a continuous ITB trial during the years 2006-2012.

METHODS

Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. A successful trial was defined as a one-level reduction in lower limb modified Ashworth scores in key spastic lower limb muscles identified for each individual patient. Subjective improvement in function or ease of performing functional tasks also were monitored.

MAIN OUTCOME MEASURES

Modified Ashworth scores, functional mobility in ambulatory patients only, and the incidence and severity of adverse events during the trial and up to 1 year after implantation.

RESULTS

Spasticity significantly decreased during the trial. Average ambulation distance was unchanged, although 34% of ambulatory patients progressed to a less restrictive assistive device by trial completion. Adverse events (AEs) occurred in 26 patients. Minor AEs were seen in 18 patients, with the most common being nausea, transient urinary retention, and headache. Pumps were implanted in 86% of patients; 14% did not receive a pump because of AEs or because goals were not met. Six patients had their pump removed at 12 months for the following reasons: pump malfunctions (3), skin breakdown around the pump (1), infection (1), and expectations not met (1).

CONCLUSIONS

Continuous trials via an external catheter could be an option if patients and clinicians desire a comprehensive assessment of systemic and functional effects of ITB before pump implantation. The majority of AEs were minor and resolved spontaneously, and the most effective starting intrathecal dose was determined by pump insertion.

Thermosensitive injectable hyaluronic acid hydrogel for adipose tissue engineering

A series of thermosensitive copolymer hydrogels, aminated hyaluronic acid-g-poly(N-isopropylacrylamide) (AHA-g-PNIPAAm), were synthesized by coupling carboxylic end-capped PNIPAAm (PNIPAAm-COOH) to AHA through amide bond linkages. AHA was prepared by grafting adipic dihydrazide to the HA backbone and PNIPAAm-COOH copolymer was synthesized via a facile thermo-radical polymerization technique by polymerization of NIPAAm using 4,4'-azobis(4-cyanovaleric acid) as an initiator, respectively. The structure of AHA and AHA-g-PNIPAAm copolymer was determined by (1)H NMR. Two AHA-g-PNIPAAm copolymers with different weight ratios of PNIPAAm on the applicability of injectable hydrogels were characterized. The lower critical solution temperature (LCST) of AHA-g-PNIPAAm copolymers in PBS were measured as approximately 30 degrees C by rheological analysis, regardless of the grafting degrees. Enzymatic resistance of AHA-g-PNIPAAm hydrogels with 28% and 53% of PNIPAAm in 100U/mL hyaluronidase/PBS at 37 degrees C was 12.3% and 37.6% over 28 days, respectively. Equilibrium swelling ratios of AHA-g-PNIPAAm hydrogels with 28% of PNIPAAm were 21.5, and significantly decreased to 13.3 with 53% of PNIPAAm in PBS at 37 degrees C. Results from SEM observations confirm a porous 3D AHA-g-PNIPAAm hydrogel structure with interconnected pores after freeze-drying and the pore diameter depends on the weight ratios of PNIPAAm. Encapsulation of human adipose-derived stem cells (ASCs) within hydrogels showed the AHA-g-PNIPAAm copolymers were noncytotoxic and preserved the viability of the entrapped cells. A preliminary in vivo study demonstrated the usefulness of the AHA-g-PNIPAAm copolymer as an injectable hydrogel for adipose tissue engineering. This newly described thermoresponsive AHA-g-PNIPAAm copolymer demonstrated attractive properties to serve as cell or pharmaceutical delivery vehicles for a variety of tissue engineering applications.

Comparison of Video Laryngoscopy Technologies

Indirect laryngoscopy allows practitioners to “see around the corner” of a patient's airway during intubation. Inadequate airway management is a major contributor to patient injury, morbidity and mortality. The purpose of the present study was to evaluate the video quality of commercially available video laryngoscopy systems. A team of four investigators at the University of Nebraska at Omaha and the Peter Kiewit Institute performed intubation simulations using a number of video laryngoscopy systems. Testing was done with a Laerdal Difficult Airway Manikin (Laerdal Medical Corp., Wappingers Falls, NY) in a setting that simulated difficult airways, adverse lighting conditions and various system configurations (e.g., maximizing screen contrast, minimizing screen brightness, maximizing screen color hue, etc.). Systems included the STORZ C-MACTM (KARL STORZ Endoscopy, Tuttlingen, Germany), a prototype developed by STORZ (a McIntosh #3 video blade with USB connectivity to an ultra mobile PC; “UMPC”) and a GlideScope® Portable GUL (Verathon Inc., Bothell, WA). Equipment was evaluated based on investigator's perceptions of the color (“C”), clarity (“L”) and brightness (“B”) of the image onscreen for each of the systems. Perceptions were given one of three possible ratings: High=3, Moderate=2 or Low=1. Statistics were performed using a two-tailed Wilcoxon Rank Sum test for independent samples. A summary of the results of the testing are shown below (shown as “Mean±Standard Deviation”):

• C-MAC–L=2.13±0.99, C=1.75±0.89, B=2.5±0.93, Total=6.38±2.5

• GlideScope®–L=2.38±0.92, C=1.38±0.52, B=2.38±0.92, Total=6.13±1.96

• UMPC–L=1.88±0.83, C=1.75±1.04, B=1.88±0.83, Total=5.5±2.2

Testing showed that there were no significant differences between image clarity, color, brightness or overall score of any of the tested systems (α=0.05). Since there were no significant differences in video quality between the three systems, the choice of system falls to user preference, which can vary from person to person, and qualitative analysis of features that are outside the scope of this study. Investigators plan to evaluate additional video laryngoscopy solutions in an effort to create a platform-agnostic video laryngoscopy suite. Funding by KARL STORZ Endoscopy. Investigators were blinded to funding source until after testing was completed. The authors wish to thank Dr. W. Bosseau Murray for his insightful comments.

Femoral guide breakage during the anteromedial portal technique used for ACL reconstruction

Positioning of the femoral tunnel is very important in ACL reconstruction and it is often recommended to use an anteromedial portal technique in order to create the tunnel. This technique is more demanding but it gives a surgeon more freedom to place the ACL graft in an anatomical position compared to the transtibial technique. A case of an intraarticular femoral guide breakage associated with this particular technique is presented. That being said, the aim of this paper is not only to present this rare complication following arthroscopic reconstruction of ACL, but also to indicate how to prevent, diagnose and treat this undesired event.

Reconstruction of chronic patellar tendon rupture with contralateral BTB autograft: a case report

Chronic patellar tendon rupture is a rare disabling injury that is technically difficult to repair. Many different surgical methods have been reported for the reconstruction of chronic patellar tendon ruptures. We are reporting the use of contralateral bone-tendon-bone (BTB) autograft for chronic patellar tendon rupture reconstruction followed by double-wire loop reinforcement and without postoperative immobilization. One year after the operation, our patient had full knee extension and up to 130 degrees of flexion. He had good quadriceps strength, and isokinetic muscle testing showed no deficit comparing to his right leg. Patient returned to playing basketball in his spare time, without having any limitation.

Anterior cruciate ligament reconstruction using compressed bone-hamstring-bone graft

Strong initial fixation of the graft is essential for successful early rehabilitation before full graft incorporation. The modified bone-hamstring-bone (BHB) composite graft procedure is a hybrid method that lacks the disadvantages of the bone-patellar tendon-bone and semitendinosus and gracilis tendon methods while retaining the advantages of these methods. We describe the modified BHB composite graft procedure used by our surgical team. Two cancellous bone cylinders, 2 cm long and 8 mm in diameter, were taken out of the tibial tunnel and fixed to both ends of the graft by use of sutures. One end of the graft was put into a pressing device to achieve a graft diameter of 9 or 10 mm, and then the other end was pressed. By doing so, very strong end parts of the graft were obtained. The graft was then passed through the tibia into the femoral socket, and once the graft had been properly positioned in the tunnel, it was fixed with round cannulated interference screws (RCI; Smith & Nephew Endoscopy, Andover, MA). This technique of BHB graft preparation allows precise and strong early fixation, promotes biologic fixation, and does not cause patellofemoral joint disorders.

Pseudoaneurysm of the medial inferior genicular artery following anterior cruciate ligament reconstruction with hamstring tendon autograft

Vascular injuries associated with arthroscopic surgery of the knee are uncommon. Pseudoaneurysm of the medial inferior genicular artery after hamstring tendon ACL reconstruction has not been reported yet. Diagnosis can be obtained clinically if continuous filling of the drain, hard and painful swelling of the lower leg, pulsatile swelling or mass in the region of the affected joint, are present. Definitive confirmation of the diagnosis can be achieved by sonography and angiography. The method of treatment consists of simple surgical wound exploration and ligation of the affected vessel.

Treatment of the knee stiffness caused by partial patellectomy--technical tricks

Partial patellectomy is advised in treating comminuted fractures of patella when accurate reduction and stable fixation cannot be achieved. Usually, after partial patellectomy, the tendon-to-bone junction requires prolonged protection. One of the effects of the prolonged immobilization is lack of knee flexion. Stiffness of the knee was treated with manipulation under anaesthesia. In order to protect patellar ligament insertion to the patella remnant, a Steinmann pin was put through tibial tuberosity, a metal wire was pulled through the patella remnant and tied firmly to the pin. Gentle manipulation was performed and full flexion of the knee was achieved without damaging bone ligament complex.

Protection of the bone-tendon-bone graft during anterior cruciate ligament reconstruction

Damage of graft fibers is a complication that can happen during arthroscopic reconstruction of the anterior cruciate ligament. It usually occurs while pulling the neoligament through the tibial tunnel, inserting the femoral screw, or doing additional notchplasty. Protection of the graft with a polyethylene tube can reduce the risk of graft laceration.

Concomitant plantar tarsometatarsal (Lisfranc) and metatarsophalangeal joint dislocations

We report an unusual case of concomitant plantar tarsometatarsal (Lisfranc) and 1st and 2nd metatarsophalangeal (MTP) joint dislocations and fracture of the neck of the third metatarsal bone which has never been reported before. The plantar dislocation of the Lisfranc joint was treated by open reduction and fixation with K-wires; the dislocations of the MTP joints and neck fracture of the third metatarsal bone were treated by closed reduction and percutaneous fixation with K-wires and immobilized with a plaster cast. At the 5 year follow-up examination, our patient had no complaints, but the radiograph showed degenerative changes of the Lisfranc and the 1st MTP joint.

Broken blade in the knee: A complication of arthroscopic meniscectomy

Arthroscopic surgery has a very low incidence of intraoperative complications. However, while the authors were using a No. 11 blade to resect the anterior horn of a meniscus, the blade broke and the fragment flew into the posterior knee compartment. The only way to remove it was to make an incision over the popliteal area. We describe this complication to show that improvisation and use of inappropriate surgical instruments can lead to serious problems and the failure of arthroscopic procedures.

A new positioning device for precise femoral insertion of the anterior cruciate ligament autograft

Optimal anatomical replacement of anterior cruciate ligament (ACL) is essential for achieving knee stability. Several methods for localizing a correct center of femoral insertion of the ACL graft and identifying a center of the femoral tunnel have been proposed, including free-hand drilling with "eyeballing," the use of tensiometers or isometers, fluoroscopic or radioscopic control, and aiming devices. We present a new positioning device for precise femoral insertion of the ACL autograft based on preoperative radiographic measurements (quadrant method) for locating the femoral ACL insertion. The aim was to find the best placement in the individual knee considering the wide variations among individuals and to decrease the likelihood of the surgeon making a mistake in localizing the optimal position of femoral insertion of the ACL. In comparison to other positioning procedures this method provides an exact preoperative planning of femoral insertion of the ACL and eliminates numerous sources of errors.

Broken Ender nails after fixation of concomitant ipsilateral fractures of the femoral neck and shaft

Concomitant ipsilateral fractures of the upper part and shaft of the femur are uncommon injuries. Because of the small number of cases reported and the diversity of devices used, no single type of internal fixation stands out as the best treatment for both of these fractures. This report describes a case of concomitant ipsilateral fractures of the femoral neck and shaft that is further distinguished by a rare complication: breakage of Ender nails after fixation.

Carpometacarpal dislocation of the thumb associated with ipsilateral fracture of the distal radius

An acute carpometacarpal (CMC) dislocation of the thumb is itself an extremely rare injury, but one associated with a fracture of the distal radius has never before been reported. In our case, the fracture of the distal radius was treated by closed reduction and immobilization with a plaster cast, whereas the dislocation of the CMC of the thumb was treated with closed reduction, percutaneous fixation with Kirschner wires, and immobilization with a plaster cast. At the patient's two-year follow-up examination, the distal radius fracture displayed successful functional and radiographic results, but a subluxation of the CMC joint was evident.