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Background:The Utrecht Scale for Evaluation of Rehabilitation-Participation Restrictions scale (USER-P-R) is a promising patient-reported outcome measure, but has currently not been validated in a hospital-based stroke population. Objective:To examine psychometric properties of the USER-P-R in a hospital-based stroke population 3 months after stroke onset. Methods:Cross-sectional study including 359 individuals with stroke recruited through 6 Dutch hospitals. The USER-P-R, EuroQol 5-dimensional 5-level questionnaire (EQ-5D-5 L), Patient Reported Outcomes Measurement Information System 10-Question Global Health Short Form (PROMIS-10), modified Rankin Scale (mRS) and two items on perceived decrease in health and activities post-stroke were administered in a telephone interview 3 months after stroke. The internal consistency, distribution, floor/ceiling effects, convergent validity and discriminant ability of the USER-P-R were calculated. Results:Of all participants, 96.9% were living at home and 50.9% experienced no or minimal disabilities (mRS 0-1). The USER-P-R showed high internal consistency (alpha = 0.90) and a non-normal left-skewed distribution with a ceiling effect (21.4% maximum scores). A substantial proportion of participants with minimal disabilities (mRS 1) experienced restrictions on USER-P-R items (range 11.9-48.5%). The USER-P-R correlated strongly with the EQ-5D-5 L, PROMIS-10 and mRS. The USER-P-R showed excellent discriminant ability in more severely affected individuals with stroke, whereas its discriminant ability in less affected individuals was moderate. Conclusions:The USER-P-R shows good measurement properties and provides additional patient-reported information, proving its usefulness as an instrument to evaluate participation after 3 months in a hospital-based stroke population.

PURPOSE: Upper blepharoplasty may be related to dry eye symptoms since the function of the orbicularis oculi muscle may affect the tear film. We aimed to assess the effect of blepharoplasty with or without the removal of a strip of orbicularis oculi muscle on tear film dynamics and dry eye symptoms.METHODS: A double-blind, randomized, controlled trial comparing upper blepharoplasty without (group A) or with (group B) orbicularis oculi muscle excision was performed on 54 healthy Caucasian patients. Tear film dynamics and dry eye symptoms were evaluated using multiple dry eye parameters, i.e. tear osmolarity, Schirmer test I, corneal/conjunctival staining, tear break-up time (TBUT), Oxford Scheme, Sicca Ocular Staining Score and Ocular Surface Disease Index questionnaire. All the parameters were assessed preoperatively and 6 and 12 months after upper blepharoplasty. All the groups' outcomes were compared.RESULTS: The differences were not significant between the two upper blepharoplasty techniques regarding most of the above-mentioned outcomes. Subjective symptoms of ocular irritation, consistent with dry eye disease and vision-related impairment, were reduced after upper blepharoplasty independent of the type of the technique applied, while the pre and postoperative outcomes of the objective tear dynamics did not differ 12 months after surgery. However, group B demonstrated a significant increase in tear osmolarity and TBUT at the 6-month follow-up visit.CONCLUSION: An upper blepharoplasty alleviates subjective dry eye complaints in the long term, while not changing the tear dynamics. The improvement was independent of the blepharoplasty technique used.

A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.

Background. Ankle fractures are some of the most common injuries seen in the emergency department. Malunited ankle fractures are uncommon. Patients with malunion frequently present with multiple complaints. Radiographs often show abnormalities in anatomical alignment. Aim. To evaluate the anatomical alignment on radiographic imaging in patients with malunited ankle fractures. Secondary aims were to evaluate patient satisfaction after reconstruction and to investigate the relationships between radiological alignment and functional outcome. Methods. All consecutive patients (n = 25) treated for a fibula malunion between January 1, 2002, and September 1, 2017, were included. The primary outcome was anatomical alignment of the ankle mortise. The talocrural angle (TCA), talar tilt (TT), and medial clear space (MCS) were used to investigate to what extent revision surgery had improved alignment. The patient-related outcome measure consisted of the Olerud and Molander Ankle Score (OMAS). To assess quality of life (QoL) the EQ-5D-5L was used. Results. The median TCA was 78.4° before revision and 79.25° after revision; P = .297. The median TT was 2.95° before revision and 0.70° after; P < .001. The MCS before revision was 5.2 mm and 3.17 mm after; P < .000). The OMAS had a median of 67.5 points. Analysis of the QoL questionnaires yielded a score of 0.84 points. Conclusion. Anatomical alignment improves significantly after revision surgery of malunited ankles. Measurements of the TCA appeared less useful in determining the anatomical alignment. In our series, 60% of patients reported good to excellent results. The QoL scores of our patient were comparable to those in the healthy population in the Netherlands. Levels of Evidence: Level IV: Case series

Purpose This study assessed adherence to, feasibility of, and barriers and facilitators of implementation of an app developed to monitor and follow-up with pain in children with cancer at home. Methods Children (8–18 years) receiving cancer treatment (all diagnoses) or their parents (of children aged 0–7 years) used the KLIK Pain Monitor app for 3 weeks. Pain was assessed twice daily using an 11-point numeric rating scale (NRS-11) (ranging from 0 to 10). Healthcare professionals (HCP’s) from the hospital’s Pediatric Pain Service were instructed to follow-up with clinically significant pain scores (≥ 4) within 120 min (scores 4–6) or 30 min (scores 7–10). Adherence, feasibility, and implementation outcomes were assessed using questionnaires, app log data, and interviews. Results Twenty-seven children (M age = 7.3 years, 51.8% male) and six HCP’s participated. Sixty-three percent (N = 17) of families used the app on a daily basis during three weeks, and 18.5% (N = 5) reported pain scores twice daily during that time (family adherence). Twelve out of 27 children (44.4%) reported a clinically significant pain score at least once. In 70% (14/20) of clinically significant pain scores, HCP’s followed-up with families within the set timeframe (HCP adherence). Outcomes reveal feasibility for the majority of app functions (i.e., positive evaluation by ≥ 70% families/HCP’s), and non-feasible aspects could be resolved. Identified barriers and facilitators were used to improve future implementation efforts. Conclusion Use of the KLIK Pain Monitor app seems feasible. Future research will determine its effectiveness in reducing pain in children with cancer at home.

Aims We identified the first Belgian SCN5A founder mutation, c.4813 + 3_4813 + 6dupGGGT. To describe the clinical spectrum and disease severity associated with this mutation, clinical data of 101 SCN5A founder mutation carriers and 46 non-mutation carrying family members from 25 Belgian families were collected. Methods and results The SCN5A founder mutation was confirmed by haplotype analysis. The clinical history and electrocardiographic parameters of the mutation carriers and their family members were gathered and compared. A cardiac electrical abnormality was observed in the majority (82%) of the mutation carriers. Cardiac conduction defects, defined as PR or QRS prolongation on electrocardiogram (ECG), were most frequent, occurring in 65% of the mutation carriers. Brugada syndrome (BrS) was the second most prevalent phenotype identified in 52%, followed by atrial dysrythmia in 11%. Overall, 33% of tested mutation carriers had a normal sodium channel blocker test. Negative tests were more common in family members distantly related to the proband. Overall, 23% of the mutation carriers were symptomatic, with 8% displaying major adverse events. As many as 13% of the patients tested with a sodium blocker developed ventricular arrhythmia. One family member who did not carry the founder mutation was diagnosed with BrS. Conclusion The high prevalence of symptoms and sensitivity to sodium channel blockers in our founder population highlights the adverse effect of the founder mutation on cardiac conduction. The large phenotypical heterogeneity, variable penetrance, and even non-segregation suggest that other genetic (and environmental) factors modify the disease expression, severity, and outcome in these families.

The brain's endogenous capacity to restore damaged myelin deteriorates during the course of demyelinating disorders. Currently, no treatment options are available to establish remyelination. Chronic demyelination leads to damaged axons and irreversible destruction of the central nervous system (CNS). We identified two promising therapeutic candidates which enhance remyelination: oncostatin M (OSM), a member of the interleukin-6 family, and downstream mediator tissue inhibitor of metalloproteinases-1 (TIMP-1). While remyelination was completely abrogated in OSMR beta knockout (KO) mice, OSM overexpression in the chronically demyelinated CNS established remyelination. Astrocytic TIMP-1 was demonstrated to play a pivotal role in OSM-mediated remyelination. Astrocyte-derived TIMP-1 drove differentiation of oligodendrocyte precursor cells into mature oligodendrocytes in vitro. In vivo, TIMP-1 deficiency completely abolished spontaneous remyelination, phenocopying OSMR beta KO mice. Finally, TIMP-1 was expressed by human astrocytes in demyelinated multiple sclerosis lesions, confirming the human value of our findings. Taken together, OSM and its downstream mediator TIMP-1 have the therapeutic potential to boost remyelination in demyelinating disorders. We thank Dr. Tom Struys, Katrien Wauterickx, and Joke Vanhoof for excellent technical assistance. This work was financially supported by grants from the Research Foundation of Flanders (FWO Vlaanderen, G04441N, G050617N, G0A5716N, and 1106817N), the Interuniversity Attraction Poles (IUAP-P7-39), the Belgian MS-Liga and the Charcot Foundation of Belgium, Methusalem NEURONET, the European FP7 project, HEALTH-F2-2011-278850 (INMiND), and Bijzonder Onderzoeksfonds (BOF)-UHasselt. Hellings, N (reprint author), Hasselt Univ, Biomed Res Inst, Dept Immunol, B-3590 Diepenbeek, Belgium. niels.hellings@uhasselt.be

INTRODUCTION: Foot and ankle injuries are common. Radiographic assessment is difficult because of the complex anatomy. In the past decade SPECT/CT made its introduction in assessing bone pathology, it combines both morphologic and pathologic imaging in one image aiming to increase sensitivity and specificity when compared with MRI or CT alone. The purpose of this review was to provide a literature overview on the diagnostic value of SPECT/CT in foot and ankle pathology.METHODS: A literature search was conducted in the databases of PubMed and EMBASE between January 2004 and September 2019 for articles describing the diagnostic value of SPECT/CT in foot and ankle pathology. For assessment of methodological quality of each study included in the analysis, QUADAS-2 checklist was used. Main outcomes were change of management, improved diagnosis and symptomatic improvement.RESULTS: A total of eight studies were identified describing the diagnostic value of SPECT/CT in foot and ankle pathology based on patient data. The combined analysis shows that change of management and improved diagnosis occurred in 48-62% and 40-79% of the patients when compared with other imaging modalities and/or clinical assessment. Symptomatic improvement due to treatment based on SPECT/CT findings occurred in 92% of the patients.CONCLUSION: SPECT/CT is useful when diagnosis based on other imaging modalities is inconclusive or when treatment based on these modalities does not lead to the desired symptomatic improvement.

Previous literature fails to offer firms consistent guidelines on how successful managers may enhance or reduce the potential to learn from frontline service encounters. In addressing this research gap, this study contributes to the frontline employee (FLE) literature by 1) investigating the contingency role of managers’ perceived career success in FLEs’ personal learning process, 2) distinguishing between FLEs’ service-related and context-related personal learning, and 3) accounting for both exploratory and exploitative learning. This study uses two datasets: an exploratory dataset on 253 FLEs and a multilevel and multisource dataset on 444 FLEs and 55 service managers. Findings reveal that managers who are unsuccessful in their careers still stimulate frontline learning processes, but their subordinates generally use only their service-related personal learning to generate ideas for service improvement. Successful managers are better able to guide their FLEs in how to turn context-related learning into service improvement.

OBJECTIVE: To determine differences in participation problems between diagnostic groups and to examine diagnosis as a determinant of participation with and without statistically accounting for confounders.DESIGN: Secondary analyses of data from 8 studies.SETTING: Community, the Netherlands.PARTICIPANTS: Participants (N=1735) in diagnostic groups: stroke (n=534), subarachnoid hemorrhage (n=104), other acquired brain injury (n=163), progressive neurologic diseases (n=112), acute coronary syndrome (n=536), and spinal cord injury (n=286).INTERVENTIONS: Not applicable.MAIN OUTCOME MEASURES: Participation was measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation. This measure has 3 scales: Restrictions, Satisfaction, and Frequency. In this study, scores were also computed for 3 domains across these scales: Productivity, Leisure, and Social. Scores ranged from 0 (worst) up to 100 (best). Possible confounders were age, sex, level of education, marital status, and time since onset of the condition.RESULTS: Significant differences were found in levels of participation between diagnostic groups. Individuals with acute coronary syndrome showed better participation scores in all scales and domains compared with most or all other diagnostic groups, except for the Social domain. Individuals with progressive neurologic diseases showed the lowest (worst) Restriction and Satisfaction scores, whereas those with stroke showed the lowest Frequency scores. After correcting for confounders, diagnosis explained significant proportions of the variance of participation (Frequency, 6.4%; Restrictions, 15.1%; Satisfaction, 5.1%; Productivity, 13.2%; Leisure, 13.8%; Social, 6.9%).CONCLUSIONS: Participation problems occurred in all 6 diagnostic groups within this study. Differences were found in participation between diagnostic groups, demonstrating diagnosis-specific participation profiles, including after correcting for confounders.

Background: Talar head fractures account for 2.6% to 10% of all talar fractures and are often associated with concomitant musculoskeletal injuries. The current literature only describes a total of 14 patients with talar head fractures and, with that, guidelines for management are lacking. The aim of the current study was to evaluate the management and long-term outcome of patients who have hindfoot trauma with concomitant talar head fractures. Methods: This study includes a retrospective cohort of patients with talar head fractures. Patient characteristics, trauma mechanism, fracture characteristics, treatment, follow-up, and complications were reported. Functional outcome was assessed using the Foot Function Index (FFI) and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Quality of life was measured by the EuroQol-5D (EQ-5D). Twenty-one patients with acute fractures of the talar head were identified. The mean follow-up time was 4.9 years. Results: All patients sustained additional ipsilateral foot and/or ankle injuries. Fifteen patients had operative management of their talar head fracture. There were no postoperative wound infections and no cases of avascular necrosis. All fractures united, and 29% of patients developed posttraumatic osteoarthritis. The overall mean FFI score index was 34.2, and the mean AOFAS score was 70.7. The mean EQ-5D index score was 0.74. Conclusion: Talar head fractures always coincided with other (foot) fractures. Management and long-term functional outcome were affected by the extent of associated injuries. Due to the low incidence and high complexity of talar head fractures, early referral to dedicated foot surgeons and centralization of complex foot surgery is recommended. Level of Evidence: Level IV, retrospective case series.

Results of a post hoc analysis of urinary dipeptidyl peptidase-4 (DPP-4) protein as a predictor of urine albumin-to-creatinine ratio (UACR) response to linagliptin treatment based on MARLINA-T2D trial data are described. MARLINA was a 24-week, phase 3b, multinational, placebo-controlled clinical trial, in which patients with type 2 diabetes (T2D), HbA1c 6.5%-10.0% and UACR 30-3000 mg/g (n = 360) were treated with linagliptin or placebo. After 24 weeks of treatment, linagliptin significantly inhibited urinary DPP-4 activity and increased urinary DPP-4 protein. Furthermore, medium urinary DPP-4 protein levels (between 5.5 and 7.5 natural logarithmic [ln] μg/g creatinine) at baseline allowed for prediction of improved UACR in linagliptin-treated individuals. In patients with lower or higher levels of urinary DPP-4 protein at baseline, no association between linagliptin treatment and improved UACR was present. This might suggest a varying degree of importance of DPP-4 as a pathophysiological factor in T2D-associated kidney disease. In summary, urinary DPP-4 might be a useful predictive biomarker for UACR improvement by linagliptin.

Background Renal hyperparathyroidism is a disease entity that is complex and poorly understood. Although there are guidelines regarding how to manage this patient group, evidence is scarce. Therefore, this survey-based study aims to map the physicians’ attitude in terms of preference for management of renal hyperparathyroidism and the influence of patient and respondent factors. Methods A survey was sent to Dutch societies of nephrology, endocrinology, and surgeons with interest in endocrine surgery. The survey consisted of eight case vignettes of renal hyperparathyroidism patients who were on hemodialysis and suitable for kidney transplantation, and varied in one of three patient variables import for decision making: age (40 vs. 65 years), parathyroid hormone (40 vs. 90 pmol/L), and serum calcium level (2.25 vs. 2.8 mmol/L). For each case, respondents could choose between maintaining conservative treatment (active vitamin D metabolites), calcimimetics, or subtotal parathyroidectomy as their treatment of choice. Categorical multilevel logistic models were used to investigate the association of patient and respondent variables with treatment preference. The influence of patient variables was determined independently of each other and by means of logistic regression the probabilities of treatment choice were calculated. Results In total, 115 surveys were included in the analysis. In 6 out of 8 cases, less than two-thirds of respondents agreed on the most favoured treatment. Among patient characteristics, the main disincentive for respondents not to choose conservative therapy was an elevated serum calcium level (subtotal parathyroidectomy vs conservative OR 93.1, 95%-CI: 48.39–179.07 and calcimimetics vs conservative OR 31.2 95%-CI: 18.58–52.30). Additionally, the most significant treatment differences were found between medical specialties and the experience of the respondents, expressed as the amount of cases the physician was involved in during the past year. Conclusions Elevated serum calcium levels were widely recognized and the prime reason for respondents to abandon conservative treatment. However, considerable disagreement in treatment preferences remained throughout the cases, demonstrating the current literature available being inconclusive in guiding physicians. Therefore, a high-quality trial comparing subtotal parathyroidectomy to medical treatment is needed to determine optimal treatment.

Background Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA. Methods A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation. Results We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95–0.99) for the anterior, 96% (95% CI 0.92–0.98) for the lateral and 96% (95% CI 0.68–1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93–0.98) and plate-fixation 99% (95% CI 0.96–0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance. Conclusion This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA. LEVEL OF EVIDENCE Level IIa.

OBJECTIVES: To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries. DATA SOURCES: A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal." STUDY SELECTION: Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS. DATA EXTRACTION: The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet. DATA SYNTHESIS: The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified. CONCLUSIONS: The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura.Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura.Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities.Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3).Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance.Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.OPERATIONSZIEL: Die Tibiavorderkante mit dem Tuberculum anterius tibiae dient als Ansatz für das Lig. tibiofibulare anterius. Sie kann als vorderer oder „vierter“ Knöchel bezeichnet werden. Ziel der Osteosynthese dislozierter Fragmente ist die knöcherne Stabilisierung der vorderen Syndesmose und die Wiederherstellung der Incisura tibiae für die distale Fibula.Dislozierte Gelenkfrakturen der Tibiavorderkante, Frakturen mit Verwerfung der vorderen Tibiainzisur, Frakturen mit Intermediärfragment(en), Impression des vorderen Tibiaplafonds, instabile Avulsionen des Lig. tibiofibulare anterius oder in den Syndesmosenspalt eingeschlagene Fragmente.Kritische Weichteilverhältnisse im Zugangsbereich, Ablehnung der Operation durch den Patienten, kritischer Allgemeinzustand des Patienten.Anterolateraler Zugang über dem Tuberculum anterius tibiae. Identifikation und Mobilisierung des Tibiavorderkantenfragments ohne Dissektion des Lig. tibifibulare anterius. Reposition des Fragments mit einer spitzen Repositionszange. Fixierung extraartikulärer Avulsionsfrakturen mit Nahtanker. Schraubenosteosynthese größerer Fragmente mit Beteiligung der Gelenkfläche und Inzisur. Anhebung, Wiederherstellung der Gelenkfläche, Spongiosaplastik, wenn erforderlich, und anteriore Plattenosteosynthese von Impressionsfrakturen des vorderen Tibiaplafonds.Mobilisation im Verbandsstiefel oder Castverband mit Teilbelastung (15–20 kg) für 6–8 Wochen je nach Frakturmuster, Knochenqualität und Patientencompliance.Nur wenige Studien berichten über Resultate nach der Osteosynthese von Tibiavorderkantenfrakturen bei Erwachsenen. Bei ausbleibender Fixierung dislozierter Fragmente werden Pseudarthrosen beschrieben. Bei der Versorgung von Sprunggelenkfrakturen übersehene Tibiavorderkantenfragmente können zu einer Fehlplatzierung der distalen Fibula in der Incisura fibularis tibiae mit nachfolgender Inkongruenz der Knöchelgabel und der Notwendigkeit von Revisionsoperationen führen. Sekundäre avaskuläre Nekrosen des anterolateralen Tibiaplafonds können nach Impaktionsverletzungen entstehen.

Strong disciplinary academic fragmentation and sectoral division in policies lead to problems regarding the management of landscapes. As a result, there is a focus on the preservation and development of either cultural or natural landscapes. We argue that framing landscapes as “natural” or “cultural” will not help sustainable management. The goal of this paper is to show that even what is referred to as nature, virtually always features an intricate combination of physical geography, biology, and cultural history. It provides an analytical framework that visualizes the three forces at play in physical landscapes. Therefore, we introduce a diachronic triangular approach to study and manage landscapes from a holistic point of view, allowing an exchange of different perspectives. To test this approach, we have applied our model to a diachronic case study on Wadden Sea salt marshes. That area has been influenced by physical-geographical, biological, and cultural landscape forces, which are still visible in the landscape to a large extent. By placing different landscape zones in the triangular concept for different time periods, we can identify and visualize these driving forces through time for this specific landscape. These all play their specific roles in the appearance of the landscape over time in a close mutual interconnection. More importantly, we show that the diverse and complex interplay between these forces makes the current-day landscape what it is. We therefore conclude that the diachronic triangular approach provides a conceptual tool to define and operationalize landscape management in the Wadden Sea area. We welcome similar approaches in other landscapes to assess the usefulness of the diachronic triangular landscape approach.

Background Several protein-bound uraemic toxins (PBUTs) have been associated with cardiovascular (CV) and all-cause mortality in chronic kidney disease (CKD) but the degree to which this is the case per individual PBUT and the pathophysiological mechanism have only partially been unraveled. Methods We compared the prognostic value of both total and free concentrations of five PBUTs [p-cresyl sulfate (pCS), p-cresyl glucuronide, indoxyl sulfate, indole acetic acid and hippuric acid] in a cohort of 523 patients with non-dialysis CKD Stages G1–G5. Patients were followed prospectively for the occurrence of a fatal or non-fatal CV event as the primary endpoint and a number of other major complications as secondary endpoints. In addition, association with and the prognostic value of nine markers of endothelial activation/damage was compared. Results After a median follow-up of 5.5 years, 149 patients developed the primary endpoint. In multivariate Cox regression models adjusted for age, sex, systolic blood pressure, diabetes mellitus and estimated glomerular filtration rate, and corrected for multiple testing, only free pCS was associated with the primary endpoint {hazard ratio [HR]1.39 [95% confidence interval (CI) 1.14–1.71]; P = 0.0014}. Free pCS also correlated with a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (r = −0.114, P Conclusions Among PBUTs, free pCS shows the highest association with CV outcome in non-dialysed patients with CKD. Two markers of endothelial activation/damage that were significantly correlated with free pCS, ANGPT2 and MMP-7 were also associated with CV outcome. The hypothesis that free pCS exerts its CV toxic effects by an adverse effect on endothelial function deserves further exploration.

How innate and adaptive lung immune responses to SARS-CoV-2 synchronize during COVID-19 pneumonitis and regulate disease severity is poorly established. To address this, we applied single-cell profiling to bronchoalveolar lavages from 44 patients with mild or critical COVID-19versusnon-COVID-19 pneumonia as control. Viral RNA-tracking delineated the infection phenotype to epithelial cells, but positioned mainly neutrophils at the forefront of viral clearance activity during COVID-19. In mild disease, neutrophils could execute their antiviral function in an immunologically ‘controlled’ fashion, regulated by fully-differentiated T-helper-17 (TH17)-cells, as well as T-helper-1 (TH1)-cells, CD8+resident-memory (TRM) and partially-exhausted (TEX) T-cells with good effector functions. This was paralleled by ‘orderly’ phagocytic disposal of dead/stressed cells by fully-differentiated macrophages, otherwise characterized by anti-inflammatory and antigen-presenting characteristics, hence facilitating lung tissue repair. In critical disease, CD4+TH1- and CD8+TEX-cells were characterized by inflammation-associated stress and metabolic exhaustion, while CD4+TH17- and CD8+TRM-cells failed to differentiate. Consequently, T-cell effector function was largely impaired thereby possibly facilitating excessive neutrophil-based inflammation. This was accompanied by impaired monocyte-to-macrophage differentiation, with monocytes exhibiting an ATP-purinergic signalling-inflammasome footprint, thereby enabling COVID-19 associated fibrosis and worsening disease severity. Our work represents a major resource for understanding the lung-localised immunity and inflammation landscape during COVID-19.

Cancer-associated venous thromboembolism (VTE) is a common complication of malignancy. Patients with cancer exhibit risk factors for both recurrent VTE and major or minor bleeding. Direct oral anticoagulants (DOACs) are an attractive treatment option; however, there is a lack of consensus among national guidelines for choice between DOACs and LMWH, agent selection, dosing strategy, and duration of anticoagulation. Characteristics of the thrombotic event, the malignancy, the patient, and the anticoagulant must be considered. A systematic search of online databases was performed to identify literature on the management of cancer-associated VTE. Multiple controversies remain surrounding the optimal treatment of cancer-associated VTE.

Introduction Measuring hemodynamic characteristics of injured limbs is paramount to early identification of potentially damaging ischemic conditions, but can often prove difficult attributable to a multitude of factors. Here, we present an in vivo optical imaging technique to characterize pulsatile blood flow quality through the distal extremity in multiple animal models that replicate the signs of distal extremity ischemia. The purpose of this study is to examine the feasibility of the optical imaging technique and relevance to hemodynamic complications such as acute compartment syndrome (ACS) and nonobvious hemorrhage. Materials and Methods In one pig and six mice, three different methods were used to create ischemic conditions in the lower extremity, producing symptoms similar to what is observed in ACS. In each condition, perfusion to the distal extremity was measured with the hemodynamic detection device (HDD; Odin Technologies), an optical assessment tool for perfusion and blood flow quality. Results We observed a profound decrease in extremity perfusion immediately after onset of ischemia in all three models. In the porcine model, the HDD’s measurements demonstrated similar characteristic flow between the various measurement locations. After the tourniquet was applied, the HDD revealed a 95% decrease in normalized perfusion value (npv) while the intracompartmental pressure rose from 5 to 52 mmHg (a 47mmHg increase). After the tourniquet was removed during reperfusion, the normalized blood flow returned to baseline and the intracompartmental pressure dropped from 20 to 6 mmHg in less than 5 minutes. For each mouse, the HDD test leg demonstrated a measurement of 0.97 npv before femoral ligation and 0.05 npv after femoral ligation, an 89% decrease (P Conclusions Here, we show that a novel, optics-based sensing system can be used to diagnose and assess ACS in animal models. This technology is comparable to other standards used to monitor ACS and nonobvious hemorrhage and may also be a plausible alternative to prolonged invasive monitoring of patients with sustained extremity trauma.

The quest for the best treatment of displaced intraarticular calcaneal fractures continues. The open reduction and internal fixation of displaced intraarticular calcaneal fractures yields the best results if anatomic reduction is obtained and complications are avoided. The sinus tarsi approach is becoming the new gold standard. In cases with severe comminution or when anatomic reduction cannot be obtained, a primary subtalar arthrodesis is a valuable option, if the overall anatomy of the calcaneus is corrected first. This review discusses the open reduction and internal fixation of displaced intraarticular calcaneal fractures and the indications and technique of the primary arthrodesis.

Several biomechanical/cadaver studies have established a correlation between mechanism of injury and fracture classification in calcaneal fractures. However, this has never been backed up by clinical studies. In this study, the hypothesis is tested whether the alleged similar mechanism of injury for both feet in bilateral calcaneal fractures leads to similar fracture types. In this retrospective cross-sectional cohort study, patients with unilateral and bilateral calcaneal fractures treated between 2000 and 2017 were classified according to Essex-Lopresti and Sanders. Positive predictive values were computed, signifying the chance that the fracture type in the left foot corresponded to that in the right foot. These were compared to the a priori chance of a fracture type (percentage of fracture type in unilateral fractures) by constructing 95% confidence intervals of the positive predictive value of each fracture type. Of the 451 patients, 413 (91.6%) had unilateral and 38 (8.4%) bilateral calcaneal fractures. Mechanisms of injury were similar for uni- and bilateral fractures. Using the Essex-Lopresti fracture classification, 34 cases (90%) had the same classification in both feet, compared with 24 (63%) in the Sanders classification. The chance of a fracture type in the left, with the right foot as reference, was significantly larger than expected from a priori chance in the unilateral population. This leads to a new hypothesis, that, more than mechanism of injury, the magnitude of the impact and the position of the foot are important in predicting fracture classification in the calcaneus.

Background: Fractures of the posterior process of the talus are rare and frequently overlooked, possibly leading to pseudo-arthrosis and chronic pain. To gain more insight into the diagnosis, treatment and outcome of fractures of the posterior process of the talus (PPTF), a systematic review of the current literature was performed to provide recommendations for the management of PPTF. Methods: A literature search in the electronic databases of PubMed, EMbase, Google Scholar and Cochrane library was performed in January 2020 to identify all clinical studies on PPTF with more than three patients. Amongst other variables, the type of study, number of patients, mechanism of injury, type of fracture (anatomy), imaging modality, treatment, postoperative protocol, outcomes, complications and duration of follow-up were noted for systematic analysis of the available evidence, adherent to the PRISMA guidelines. Results: Seven original studies were included with a total of 66 patients. More than one third of patients presented with a (sub)talar joint dislocation (n = 25, 37.9%) and 51.5% sustained associated ipsilateral lower extremity fractures (n = 34). Delayed diagnosis occurred in 36.4% of patients (n = 24). Out of 48 patients with outcome data available, 41.7% (n = 20) reported impaired function. In the non-operative group, 64.7% (n = 11) had impaired functional outcome, compared to 33.3% (n = 6) in the ORIF group, and 30.8% (n = 4) in the fragment excision group (p < 0.001). One third of the patients developed one or more complications (n = 25, 37.9%), mostly found in the non-operatively treated group (73.7%, n = 14) compared to ORIF (25.0%, n = 8, p < 0.001). Conclusion: Early recognition and timely treatment is warranted in order to achieve pre-injury functional outcome and reduce morbidity. Given the significantly higher complication rate and lower return to the previous level of functionality reported after non-operative treatment, ORIF is recommended if there is (even minimal) displacement, articular involvement or if the fracture extends into the talus body.

Self-tracking technologies (STTs) in the form of smart devices and mobile applications enable consumers to monitor, analyze, and interpret personal performance data on health and physical or financial well-being. As a result of self-tracking, consumers are not only expected to check their personal performance more actively but also to implement service professionals’ advice to improve their well-being more accurately. Despite the growing popularity of STTs, empirical evidence on the extent to which STT use enhances advice compliance remains scant. A field experiment with 538 participants in a health-care setting suggests that STT use does not increase advice compliance per se. Rather, the effectiveness of STTs depends on consumers’ self-efficacy. For consumers low in self-efficacy, STT use can even undermine advice compliance. A lab experiment with 831 participants replicates and generalizes the findings to a nonmedical professional service (i.e., fitness training). As assessments of self-efficacy might be difficult in practice, service providers in health care can use consumers’ body mass index as an easy-to-measure proxy to predict STT effectiveness. Finally, the lab experiment also identifies perceived empowerment and personalization as psychological mechanisms mediating the influence of STT use on advice compliance.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

BACKGROUND: It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis.METHODS: In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133.FINDINGS: Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group.INTERPRETATION: In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis.FUNDING: The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.

Background: Three-dimensional (3D) fluoroscopy is thought to be advantageous in the open reduction and internal fixation (ORIF) of calcaneal fractures. The goal of this multicenter randomized controlled trial was to investigate the clinical effect of additional intraoperative 3D fluoroscopy on postoperative quality of reduction and fixation and patient-reported outcome as compared to conventional 2-dimensional (2D) fluoroscopy in patients with intra-articular fractures of the calcaneus. Methods: Patients were randomized to 3D or conventional 2D fluoroscopy during operative treatment of calcaneal fractures. Primary outcome was the difference in quality of fracture reduction and implant position on postoperative computed tomography (CT). Secondary endpoints included intraoperative corrections (prior to wound closure), complications, and revision surgery (after wound closure). Function and patient-reported outcome were evaluated after surgery and included range of motion, Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short-Form 36 (SF-36) questionnaires, and Kellgren-Lawrence posttraumatic osteoarthritis classification. A total of 102 calcaneal fractures were included in the study in 100 patients. Fifty fractures were randomized to the 3D group and 52 to the 2D group. Results: There was a statistically significant difference in duration of surgery between the groups (2D 125 min vs 3D 147 min; P < .001). After 3D fluoroscopy, a total of 57 intraoperative corrections were performed in 28 patients (56%). The postoperative CT scan revealed an indication for additional revision of reduction or implant position in 69% of the 3D group vs 60% in the 2D fluoroscopy group. At 2 years, there was no difference in number of revision surgery, complications, FAOS, AOFAS score, SF-36 score, or posttraumatic osteoarthritis. Conclusion: The use of intraoperative 3D fluoroscopy in the treatment of intra-articular calcaneal fractures prolongs the operative procedures without improving the quality of reduction and fixation. There was no benefit of intraoperative 3D fluoroscopy with regard to postoperative complications, quality of life, functional outcome, or posttraumatic osteoarthritis. Level of Evidence: Level I, prospective randomized controlled study.

Although upper blepharoplasty is a common cosmetic surgical intervention, a better scientific understanding of the aesthetic results and the preferred surgical technique to achieve the best aesthetic results is still needed. A systematic search using four search engines (PubMed, Embase, CINAHL, and Cochrane) was performed to identify any study on the aesthetic outcome of a solitary upper blepharoplasty; these were subjected to quality assessment for possible inclusion. Eligible studies were randomized controlled trials, controlled trials, cohort studies, and case series (n >= 10). A total of 4043 studies were assessed, of which 26 were included. Aesthetic outcomes included patient-reported outcome measures, scarring, eyebrow height, tarsal platform show, and panel or expert evaluation. Meta-analysis was not possible. Patients were generally satisfied with the aesthetic result and scar formation after an upper blepharoplasty. The amount of tarsal platform show increases, which positively affects the aesthetics. The eyebrow seems to move down slightly. The surgical technique used (skin only or skin/muscle removal) did not influence patient satisfaction or the physician-assessed aesthetic outcomes. Patients are generally satisfied after an upper blepharoplasty. The optimal design of the skin excision is still a matter of debate, especially when addressing lateral hooding. Further objective research is advised.

Many empirical studies have focused on understanding the frontline role process, which reflects the chain of effects including the antecedents and outcomes of frontline employees’ in-role behavior and extra-role behavior. A close examination of past findings reveals discrepancies across cultures. This meta-analysis provides insights into the moderating effects of national culture on the frontline role process. We build on role theory to consolidate role behavior’s antecedents to reflect the expectations emanating from four stakeholders of the frontline role: the organization, manager, peers, and customers. We formulate hypotheses on the moderating effects of national culture dimensions (i.e., power distance, individualism, masculinity, and uncertainty avoidance) and meta-analyze 105 articles, including 100 independent samples with 32,364 participants from 35 different countries, to test our predictions. The results show that customer expectations are the strongest antecedent to both in-role and extra-role behavior and furthermore confirm that the frontline role process differs across cultures. We offer managers advice on how to adapt expectations for sales and service employees across countries to enhance frontline performance evaluations, customer satisfaction, and ultimately the firm’s competitiveness. We also link our results to new frontline trends (e.g., service robots, artificial intelligence, remote service technology) and provide a future research agenda.

Horizontal axis wind turbines (HAWTs) experience three-dimensional rotational and unsteady aerodynamic phenomena at the rotor blades sections. These highly unsteady three-dimensional effects have a dramatic impact on the aerodynamic load distributions on the blades, in particular, when they occur at high angles of attack due to stall delay and dynamic stall. Unfortunately, there is no complete understanding of the flow physics yet at these unsteady 3D flow conditions, and hence, the existing published theoretical models are often incapable of modelling the impact on the turbine response realistically. The purpose of this paper is to provide an insight on the combined influence of the stall delay and dynamic stall on the blade load history of wind turbines in controlled and uncontrolled conditions. New dynamic stall vortex and nonlinear tangential force coefficient modules, which integrally take into account the three dimensional rotational effect, are also proposed in this paper. This module along with the unsteady influence of turbulent wind speed and tower shadow is implemented in a blade element momentum (BEM) model to estimate the aerodynamic loads on a rotating blade more accurately. This work presents an important step to help modelling the combined influence of the stall delay and dynamic stall on the load history of the rotating wind turbine blades which is vital to have lighter turbine blades and improved wind turbine design systems.

Purpose Proxy reports of health-related quality of life (HRQoL) are commonly used in pediatric oncology. However, it is not known if caregivers’ reports differ. This study therefore aims to compare paternal and maternal proxy reports, and explore determinants of couple disagreement (sociodemographic and medical characteristics, and parental QoL and distress). Methods Both parents completed the PedsQL generic (child’s HRQoL), Short Form-12 (own QoL) and Distress Thermometer for Parents. To assess agreement in child HRQoL, intra-class correlation coefficients (ICCs) were calculated. Differences between fathers/mothers were assessed with paired t tests. Systematic disagreement patterns were visualized with Bland–Altman plots. Characteristics of parental couples with a mean proxy difference in the highest quartile (highest proxy score minus lowest proxy score) were explored with multiple logistic regression analysis. Results Parents of 120 children with cancer (87% post-treatment, mean age 11.0 ± 5.7 years) participated. No significant differences were found between paternal and maternal proxy scores, and agreement was good on all scales (ICCs 0.65–0.83). Bland–Altman plots revealed no systematic disagreement patterns, but there was a wide range in magnitude of the differences, and differences went in both directions. Couples with a mean proxy difference (irrespective of which direction) in the highest quartile (± 20 points) were more likely to have a child in active treatment, with retinoblastoma or relapsed disease, and to diverge in their own QoL. Conclusions If proxy reports of only one parent are available, clinicians may reasonably assume that paternal and maternal reports are interchangeable. However, if in doubt, respondent’s sex is not of major importance, but clinicians should be aware of patient’s and family’s characteristics.

PRIMARY OBJECTIVE: To investigate the level of agreement and differences regarding the perception of family functioning between patients with acquired brain injury and their partners. Our hypothesis was that patients would report better family functioning than their partners.RESEARCH DESIGN: Cross-sectional studyMethods and Procedures: Baseline data were used from 77 patient-partner dyads (87.0% stroke) who were participating in the ongoing CARE4Patient and CARE4Carer trials. Family functioning was assessed using the General Functioning subscale of the McMaster Family Assessment Device (FAD-GF). Agreement was assessed with intraclass correlation coefficient, a Bland-Altman plot, percentages absolute agreement and weighted kappa values. Differences were tested with Wilcoxon signed-rank tests.MAIN OUTCOMES AND RESULTS: Patients and their partners differed in their perception of family functioning. Within-dyad agreement was poor regarding the overall FAD-GF scores with partners reporting significantly poorer family functioning compared to the patients (32.5% versus 18.2%). Agreement regarding the individual items ranged from slight to moderate.CONCLUSIONS: Health care professionals should assess family functioning after stroke in both patients and their partners, and any discrepancies should be discussed with both members of the patient-partner dyad.

Objective To identify prognostic factors for the effectiveness of needle aspiration of calcific deposits (NACD) for rotator cuff calcific tendinitis (RCCT) Methods One hundred forty-nine patients with symptomatic RCCT were included in a prospective cohort study. Pain (VAS), shoulder function (SST and DASH), and quality of life (EQ-5D) were assessed at baseline and at 3, 6, and 12 months post-NACD. Univariate analyses (independent t tests or Mann-Whitney U tests depending on the distribution of data) were performed to build a multivariable linear regression model. Stepwise regression analysis through backward elimination was performed to evaluate the effect of predefined prognostic factors on the outcome. Results Patients who underwent multiple NACD procedures had less reduction of pain (p p p p = 0.03) and EQ-5D scores (p = 0.01). A longer duration of symptoms prior to NACD was associated with less improvement of EQ-5D scores (p = 0.01). Conclusions A good initial response after NACD is associated with better outcomes at 12 months. Patients with a longer duration of symptoms prior to NACD and patients who require multiple procedures showed inferior outcomes in terms of pain reduction and improvement of quality of life. Smaller-size calcific deposits are associated with a less favorable outcome of shoulder function and quality of life scores and might therefore be less susceptible for NACD. Key Points • A good initial response to NACD is associated with a better outcome in the longer term. • A longer duration of symptoms and the need for multiple NACD procedures are associated with inferior outcomes. • Smaller-size calcific deposits seem less susceptible for NACD.

Background: The rate of surgical site infections (SSIs) after foot or ankle surgery remains high, despite the implementation of antibiotic prophylaxis. Recently, guidelines suggest a single dose of 2 g instead of 1 g of cefazolin for implant surgery; this decision is largely based on pharmacokinetic studies. However, the clinical effect of this higher dose has never been investigated in foot and ankle surgery. This retrospective cohort study investigated the effect of 2 g compared with 1 g of prophylactic cefazolin on the incidence of SSIs in foot and ankle surgery. Methods: All patients undergoing trauma-related surgery of the foot, ankle, or lower leg between September 2015 and March 2019 were included. The primary outcome was the incidence of an SSI. SSIs were compared between patients receiving 1 g and 2 g of cefazolin as surgical prophylaxis, using a propensity score to correct for possible confounders. Results: A total of 293 patients received 1 g and 126 patients received 2 g of cefazolin. The overall number of SSIs was 19 (6.5%) in the 1-g group and 6 (4.8%) in the 2-g group. Corrected for possible confounders, this was not statistically significant (OR, 0.770; P = .608). Conclusion: Even though the decrease in SSI rate from 6.5% to 4.8% was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality, and healthcare costs. Research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing SSIs in foot and ankle surgery. Level of Evidence: Level III, retrospective comparative series.

Background: Displaced intra-articular calcaneal fractures often result in permanent disability, reduced quality of life and high socio-economic costs. Since they often result in a change in geometry of the foot, pedobarography may be useful in predicting outcome at an early stage. The aim of this study was to examine whether a correlation exists between pedobarography and functional outcomes in patients with a displaced intra-articular fracture. Methods: In this systematic review, studies were included when they investigated the correlation between pedobarography and functional outcome in displaced intra-articular calcaneal fractures. Excluded were studies on

Objective: Doppler ultrasonography (DUS) is used as initial measurement to diagnose and classify carotid artery stenosis. Local distorting factors such as vascular calcification can influence the ability to obtain DUS measurements. The DUS derived maximal systolic acceleration (ACCmax) provides a different way to determine the degree of stenosis. While conventional DUS parameters are measured at the stenosis itself, ACCmax is measured distal to the internal carotid artery (ICA) stenosis. The value of ACCmax in ICA stenosis was investigated in this study. Material and Methods: All carotid artery DUS studies of a tertiary academic center were reviewed from October 2007 until December 2017. Every ICA was included once. The ACCmax was compared to conventional DUS parameters: ICA peak systolic velocity (PSV), and PSV ratio (ICA PSV/CCA PSV). ROC-curve analysis was used to evaluate accuracy of ACCmax, ICA PSV and PSV ratio as compared to CT-angiography (CTA) derived stenosis measurement as reference test. Results: The study population consisted of 947 carotid arteries and was divided into 3 groups: = 70% (128/947). Between these groups ACCmax was significantly different. Strong correlations between ACCmax and ICA PSV (R-2 0.88) and PSV ratio (R-2 0.87) were found. In ROC subanalysis, the ACCmax had a sensitivity of 90% and a specificity of 89% to diagnose a >= 70% ICA stenosis, and a sensitivity of 82% and a specificity of 88% to diagnose a >= 50% ICA stenosis. For diagnosing a >= 50% ICA stenosis the area under the curve (AUC) of ACCmax (0.88) was significantly lower than the AUC of PSV ratio (0.94) and ICA PSV (0.94). To diagnose a >= 70% ICA stenosis there were no significant differences in AUC between ACCmax (0.89), PSV ratio (0.93) and ICA PSV (0.94). Conclusions: ACCmax is an interesting additional DUS measurement in determining the degree of ICA stenosis. ACCmax is measured distal to the stenosis and is not hampered by local distorting factors at the site of the stenosis. ACCmax can accurately diagnose an ICA stenosis, but was somewhat inferior compared to ICA PSV and PSV ratio to diagnose a >= 50% ICA stenosis.

Contains fulltext : 248213.pdf (Publisher’s version ) (Open Access) AIM: To assess the dysphagia limit in children with cerebral palsy (CP) according to Eating and Drinking Ability Classification System (EDACS) level, sex, and age compared to typically developing children. METHOD: Seventy-seven children with CP (54 males, 23 females; mean age 7y 6mo, SD 2y 2mo, age range 4-12y) were assessed with the Maximum Volume Water Swallow Test. Median dysphagia limit in the CP group was compared with data of typically developing children. RESULTS: The dysphagia limit of children with CP differed significantly (p

Although leasing can be an interesting financing option from an economic point of view, family businesses are found to be less prone to lease. In this study, we examine the view of the external accountant on leasing as an alternative form of financing within family businesses. After all, as the most trusted advisor, the accountant likely has a significant influence on the financial decisions that are taken within private family businesses. By means of an exploratory qualitative study, we examine what factors influence the advice for a particular financing option and the accountant’s recommendation to lease or not to lease within family businesses. By combining the extant literature with the results of this exploratory qualitative research, we formulate propositions that form fruitful avenues for future research.

Background: Patients with chronic limb threatening ischemia have a risk of undergoing a major amputation within 1 year of nearly 30% with a substantial risk of re-amputation since wound healing is often impaired. Quantitative assessment of regional tissue viability following amputation surgery can identify patients at risk for impaired wound healing. In quantification of regional tissue perfusion, near-infrared (NIR) fluorescence imaging using Indocyanine Green (ICG) seems promising. Methods: This pilot study included adult patients undergoing lower extremity amputation surgery due to peripheral artery disease or diabetes mellitus. ICG NIR fluorescence imaging was performed within 5 days following amputation surgery using the Quest Spectrum Platform (R). Following intravenous administration of ICG, the NIR fluorescence intensity of the amputation wound was recorded for 10 minutes. The NIR fluorescence intensity videos were analyzed and if a fluorescence deficit was observed, this region was marked as "low fluorescence." All other regions were marked as "normal fluorescence." Results: Successful ICG NIR fluorescence imaging was performed in 10 patients undergoing a total of 15 amputations. No "low fluorescence" regions were observed in 11 out of 15 amputation wounds. In 10 out of these 11 amputations, no wound healing problems occurred during followup. Regions with "low fluorescence" were observed in 4 amputation wounds. Impaired wound healing corresponding to these regions was observed in all wounds and a re-amputation was necessary in 3 out of 4. When observing time-related parameters, regions with low fluorescence had a significantly longer time to maximum intensity (113 seconds vs. 32 seconds, P = 0.003) and a significantly lesser decline in outflow after five minutes (80.3% vs. 57.0%, P = 0.003). Conclusions: ICG NIR fluorescence imaging was able to predict postoperative skin necrosis in all four cases. Quantitative assessment of regional perfusion remains challenging due to influencing factors on the NIR fluorescence intensity signal, including camera angle, camera distance and ICG dosage. This was also observed in this study, contributing to a large variety in fluorescence intensity parameters among patients. To provide surgeons with reliable NIR fluorescence cut-off values for prediction of wound healing, prospective studies on the intraoperative use of this technique are required. The potential prediction of wound healing using ICG NIR fluorescence imaging will have a huge impact on patient mortality, morbidity as well as the burden of amputation surgery on health care.

Artificial Intelligence (AI) powered building control allows deriving policies that are more flexible and energy efficient than standard control. However, there are challenges: environment interaction is used to train Reinforcement Learning (RL) agents but for building control it is often not possible to use a physical environment, and creating high fidelity simulators is a difficult task. With offline RL an agent can be trained without environment interaction, it is a data-driven approach to RL. In this paper, Conservative Q-Learning (CQL), an offline RL algorithm, is used to control the temperature setpoint in a room of a university campus building. The agent is trained using only the historical data available for this room. The results show that there is potential for offline RL in the field of building control, but also that there is room for improvement and need for further research in this area.

Introduction E-cycles may offer an opportunity to increase cycling levels. However, experimental findings should be complemented with longitudinal observational studies examining the effects of starting to e-cycle on cycling levels in real-life settings. The current study among Flemish and Dutch middle-aged and older adults (≥45 years) aimed to compare changes between two time points in total (conventional + e-cycling) and conventional cycling frequencies of participants who started e-cycling against participants who did not e-cycle, who e-cycled at both time points and who stopped e-cycling. Methods Conventional and e-cycling frequencies were assessed retrospectively using a survey and participants (n = 1420) were categorized into one of four groups; (1) not e-cycling at both time points (n = 849), (2) e-cycling at both time points (n = 553), (3) started e-cycling (n = 11) and (4) stopped e-cycling (n = 7). Non-parametric repeated measures ANOVAs were applied to examine changes in total and conventional cycling frequency according to group. Results A significant interaction between group and time was observed for total and conventional cycling frequencies. Total cycling frequencies significantly decreased in all groups, except among those who started e-cycling for whom a significant increase with large effect size was observed. Conventional cycling frequencies significantly decreased in all groups, except among those who stopped e-cycling for whom no significant change was observed. Sensitivity analyses on matched groups confirmed these findings. Conclusions E-cycles appear to boost cycling frequencies among middle-aged and older adults. Future prospective observational studies in larger samples assessing cycling frequencies and durations and overall physical activity levels are necessary to confirm current findings.

Background Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. Methods This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. Discussion If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284