#Complete / Incomplete Spinal Cord Injury

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Foto de Doctors-Online.

Foto de Doctors-Online.


#Know your chest pain (evaluation by history, examination & relevant investigation)

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Resultado de imagem para chest pain

Chest pain is a common presenting symptoms of disorders that can range from trivial to life threatening.


Cardiovascular: (Angina, Myocardial infarction,Acute aortic dissection,Pericarditis)
Gastrointestinal:(Reflux esophagitis, Peptic ulcer disease, esophageal spasm)
Pulmonary: (Pneumonia, Pneumothorax, Pulmonary embolism)
Musculoskeletal: (Chest wall injuries, Herpes zoster, Costochondritis, Secondary tumors of the rib)
Emotional: (Depression)
Evaluation by history:


The character of angina is tight and crushing, while the pain from aortic dissection has a tearing quality. Esophageal reflux may be described as a burning pain, and peptic acid-related pain tends to be deep and gnawing.
Location: the pain from angina and esophageal  reflux may be located retrosternally, and they both can radiate to the jaw or down into the left arm.
The pain from pericarditis may be centrally located and radiate to the shoulders (trapezius ridge pain).
Pain from aortic dissection often radiate =s into the back and occasionally into the abdomen (depending on the extent of the dissection) . pulmonary pain can be located anywhere in the thorax.
Precipitating factors:

Angina may be precipitated by effort, a defining characteristics. Other known precipitants of angina are emotion, food and cold weather. If angina occurs at rest for more than 20 minutes it should be treated as a myocardial infarction until proven otherwise.
Esophageal reflux is often related to meals and precipitated by changes in posture, such as bending or lying.
Pain originating from pericarditis and pulmonary origin is often pleuritic, i.e worse on inspiration, however musculoskeletal pain can also be worse on breathing due to movement of the thorax.
Relieving factors:

Both esophageal spasm and angina may be relieved by GTN (glyceral trinitrite?) which relaxes smooth muscle.
Antacids will relieve the pain of esophageal reflux but not angina.
The pain associated with pericarditis may be relieved by sitting forwards.
History of trauma:

A blunt or stretching injury immediately suggests the underlying etiology of chest wall tenderness and it is important to diagnose rib fractures that can result from more severe trauma.

Emotion: Occasionally chest pain is a somatic manifestation of patients with depression or anxiety but it is essential to exclude all organic causes before accepting depression or anxiety as the underlying cause. Moreover a serious etiology may co-exist.


Temperature: Pyrexia can occur with pneumonia, myocardial infarction, pericarditis and herpes zoster infection.
Pulse: Heart rate on its own is not discriminating as pain invariably leads to tachycardia. However palpating both upper and lower limb pulses may be useful. Occasionally peripheral pulses are absent in patients with aortic dissection.
JVP: The JVP  is elevated with congestive cardiac failure and acute right ventricular failure, an occasional complication of inferior myocardial infarction and pulmonary embolism (when more than 60% of the pulmonary vascular supply is occluded).
Palpation of the chest:

Chest wall tenderness would imply a musculoskeletal cause. The presence of unilateral tenderness confined to a single or adjacent group of dermatomes would suggest either central ( vertebral or spinal origin) or peripheral nerve pathology (herpes zoster infection).

The trachea deviates away from the side of tension pneumothorax and chest expansion is decreased on the same side of pneumonia and pneumothorax. Dullness to percussion will be noted in an area of consolidation with pneumonia and hyperresonance with pneumothorax.

Auscultation of the chest:

The unilateral absence of breath sounds is consistent with a pneumothorax, more localized loss occurs over an effusion. Localized areas of crepitation suggest lobar pneumonia while widespread crepitation suggest multilobar involvement. A friction rub may be auscultated with both pericardial and pleuritic disease.

Lower limbs: hemiparesis can occur with aortic dissection, and a hot swollen, tender calf or thigh may give a clue to an underlying deep vein thrombosis.

Invetigation: General

ECG: Angina or a myocardial infarction will result in ecg changes. So it is important investigation for evaluation of chest pain.
FBC: A elevated white count will be expected with pneumonia and to a lesser extent in a myocardial infarction.(2) Serum Cardiac markers. Following a myocardial infarction, cardiac troponin rises within 6 hours and remains elevated for up to 2 weeks.
Chest X ray. It helps to rule out any pathology in the lungs and also any fracture in the ribs.
Specific investigations:

V/Q scan: It will show a mismatch in the majority of pulmonary embolism.
Pulmonary angiography: It is possible to visualise the site and extent of the embolism and it may also be possible to extract the emboli using the catheter.
CT aortography: Confirm and asses the extent and site of the dissection of the aorta.
Upper GI tract endoscopy: Esophagitis
Esophageal manometry: Abnormal esophageal pressure
The heart score for a patient of chest pain in emergency department.

Image result for heart score

It is important to perform a prompt history, examination and initial investigations in patients who present with chest pain as a number of conditions require urgent management.If tension pneumothorax is suspected as a cause of chest pain, do not wait for a chest film. Decompress the pneumothorax immediately with a large-bore cannula inserted into 2nd  intercostal space in the midclavicular line.



#Suplementos não previnem #fraturas em adultos e #idosos saudáveis

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Uma meta-análise de múltiplos ensaios randomizados não embasa o uso de suplementos de cálcio ou vitamina D ou a combinação deles para reduzir o risco de fratura de qualquer tipo em idosos saudáveis, reafirmam pesquisadores chineses.

“O aumento dos impactos sociais e econômicos para as fraturas relacionadas à osteoporose em todo o mundo faz da prevenção de tais lesões um importante objetivo de saúde pública”, escrevem o Dr. Jia-Guo Zhao, Tianjin Hospital (China) e colaboradores.

“Mas os resultados desta meta-análise mostraram que o cálcio, o cálcio mais a vitamina D, e suplementação com vitamina D isoladamente, não foram significativamente associados a uma menor incidência de fraturas do quadril, não vertebral, vertebral ou total em idosos que vivem na comunidade” observam eles.

“E estes resultados foram geralmente consistentes, independentemente de dose de cálcio ou vitamina D, sexo, história de fratura, ingesta dietética de cálcio, e concentrações séricas basais de 25-hidroxivitamina D”, concluem os autores.

O estudo foi publicado na edição de 26 de dezembro do Journal of the American Medical Association.

A meta-análise incluiu 33 ensaios clínicos randomizados envolvendo 51.145 participantes com idade superior a 50 anos. “Quatorze estudos compararam suplementos de cálcio com placebo ou nenhum tratamento”, escrevem os pesquisadores. Eles observaram uma redução de 53% no risco relativo (RR) de fratura do quadril com suplementação de cálcio (RR, 1,53; IC de 95%, 0,97 – 2,42), mas isso não foi significativo, com uma diferença absoluta de risco (DAR) de 0,01 em comparação com o placebo ou nenhum tratamento.

Da mesma forma, a redução absoluta do risco relativo com suplementação de cálcio e fraturas não-vertebrais foi de 0,95 (IC de 95%, 0,82 – 1,11), com uma DAR de -0,01. Isto não foi novamente significativo em comparação com placebo ou ausência de tratamento. Também não foi observada associação significativa entre o risco de fratura vertebral, com uma redução do risco relativo de 0,83 (IC de 95%, 0,66 – 1,05) e uma DAR de -0,01, ou em fraturas totais, com uma redução relativa do risco de 0,88 (IC de 95%, 0,75 – 1,03) e uma DAR de -0,02, em comparação com o placebo ou nenhum tratamento, acrescentam os pesquisadores.

“Dezessete estudos compararam a suplementação de vitamina D com um placebo ou nenhum tratamento”, continuam os pesquisadores. Houve novamente uma ligeira redução de 21% no risco relativo de fratura de quadril com suplementação de vitamina D em comparação com placebo ou nenhum tratamento (RR, 1,21; IC de 95%, 0,99-1,47), com DAR de 0,00.

No entanto, a diferença entre o grupo suplementado e aqueles que não usaram suplementos novamente não foi significativa, como destacaram os pesquisadores. Também não foi observada redução significativa em fraturas não-vertebrais e suplementação de vitamina D (RR de 1,10; IC de 95%, 1,00 – 1,21), com DAR de 0,01. O mesmo foi verdadeiro para as fraturas vertebrais e totais em comparação com o placebo ou nenhum tratamento, com risco relativo de fraturas vertebrais de 0,97 (IC de 95%, 0,54 – 1,77) e 1,01 para fraturas totais (IC de 95%, 0,87 – 1,17), com uma DAR de 0,00 para ambos desfechos de fratura.

Avaliando a combinação de suplementos de cálcio e vitamina D, os pesquisadores identificaram 13 ensaios nos quais a combinação foi comparada com placebo ou ausência de tratamento. O principal estudo incluído nessa subanálise foi o Women’s Health Initiative, no qual mais de 36.000 mulheres receberam cálcio e vitamina D, com ou sem terapia hormonal, ou placebo.

Novamente, os pesquisadores não encontraram associação clinicamente relevante entre o uso de vitamina D mais suplementação de cálcio e qualquer um dos desfechos de fratura. Para a fratura do quadril, o risco relativo foi de 1,09 entre os grupos com suplemento e sem suplemento (IC de 95%, 0,85 – 1,39), com DAR de 0,00. Para a fratura vertebral, a redução do risco relativo foi de 0,63 (IC de 95%, 0,29 – 1,40), com uma DAR de -0,00, enquanto que para as fraturas totais, a redução do risco relativo foi de 0,90 (IC de 95%, 0,78 – 1,04), com uma DAR de -0,01, em comparação com ausência de suplementação.

“Análises de sensibilidade que excluíram ensaios de baixa qualidade e estudos que inscreveram exclusivamente pacientes com condições médicas particulares não alteraram esses resultados”, observam os pesquisadores.

Os autores advertem que é possível que os pacientes institucionalizados ainda possam se beneficiar de suplementação de cálcio ou vitamina D, uma vez que estão sob maior risco de osteoporose devido a múltiplos fatores de estilo de vida. Assim, “os benefícios da suplementação de cálcio e vitamina D podem diferir entre pessoas que vivem na comunidade e pessoas que vivem em instituições de longa permanência”.

No entanto, entre homens e mulheres saudáveis o suficiente para viver na comunidade, os “resultados não embasam o uso rotineiro desses suplementos”, afirmam os autores.

Os autores não relataram conflitos de interesses relevantes.

JAMA. 2017;318:2466-2482. Resumo

#El #exceso de peso y el #uso de dispositivos móviles aumentan riesgo de #dolor articular

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El sobrepeso, la obesidad y el uso de dispositivos móviles incrementan el riesgo de dolor en las articulaciones, pues al tener o imprimir más peso al esqueleto, estas se dañan, según explica el director y fundador del Centro Nacional para la Educación en Dolor, en México, Alfredo Covarrubias Gómez.

Según un estudio realizado en el país, entre 15 y 17% de la población tiene alguna molestia crónica, que en ocasiones es resultado de alguna enfermedad como diabetes, lupus o cáncer, y en otras es consecuencia de hábitos poco saludables que llevan al sobrepeso u obesidad, o por el uso de dispositivos móviles.

“El solo hecho de inclinar la cabeza para ver el móvil o la tablet implica una carga de 30 kg sobre el cuello que favorece la presencia de dolores cervicales”, subraya Covarrubias.

Otro problema es que ante los altos índices de sobrepeso y obesidad en adultos y población infantil, se recomienda la activación física, pero nadie se hace responsable de que esto suceda bajo supervisión de un experto.

Al hecho de que estas personas dañan su columna vertebral y rodillas con el exceso de peso, se suman las lesiones de los llamados corredores de fin de semana, declara Covarrubias.

En su opinión se requiere de una estrategia de atención del dolor de manera óptima y eficiente, ya que incluso por la noche el malestar es más intenso debido a que algunos de los ciclos hormonales del organismo se encuentran en reposo.

En algunos países como Estados Unidos el suministro de medicamentos derivados de la morfina para el control del dolor se han vuelto un problema, por lo que la opción es prescribir analgésicos combinados para aliviarlo.

Este especialista añade que un dolor de espalda que no cede en cinco días debe ser motivo de consulta médica, ya que puede estar enmascarando un problema de salud grave como una metástasis por cáncer de próstata, entre otros.

#Prevalence of #Musculoskeletal Disorders Among #Surgeons Performing Minimally Invasive Surgery

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A Systematic Review

Chantal C. J. Alleblas, MSc; Anne Marie de Man, BSc; Lukas van den Haak, MD; Mark E. Vierhout, MD, PhD; Frank Willem Jansen, MD, PhD; Theodoor E. Nieboer, MD, PhD


Annals of Surgery. 2017;266(6):905-920.

Abstract and Introduction


Objective: The aim of this study was to review musculoskeletal disorder (MSD) prevalence among surgeons performing minimally invasive surgery.

Background: Advancements in laparoscopic surgery have primarily focused on enhancing patient benefits. However, compared with open surgery, laparoscopic surgery imposes greater ergonomic constraints on surgeons. Recent reports indicate a 73% to 88% prevalence of physical complaints among laparoscopic surgeons, which is greater than in the general working population, supporting the need to address the surgeons’ physical health.

Methods: To summarize the prevalence of MSDs among surgeons performing laparoscopic surgery, we performed a systematic review of studies addressing physical ergonomics as a determinant, and reporting MSD prevalence. On April 15 2016, we searched Pubmed, EMBASE, the Cochrane Library, Web of Science, CINAHL, and PsychINFO. Meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method.

Results: We identified 35 articles, including 7112 respondents. The weighted average prevalence of complaints was 74% [95% confidence interval (95% CI) 65–83]. We found high inconsistency across study results (I2 = 98.3%) and the overall response rate was low. If all nonresponders were without complaints, the prevalence would be 22% (95% CI 16–30).

Conclusions: From the available literature, we found a 74% prevalence of physical complaints among laparoscopic surgeons. However, the low response rates and the high inconsistency across studies leave some uncertainty, suggesting an actual prevalence of between 22% and 74%. Fatigue and MSDs impact psychomotor performance; therefore, these results warrant further investigation. Continuous changes are enacted to increase patient safety and surgical care quality, and should also include efforts to improve surgeons’ well-being.

Learning Objectives

After participating in this activity, the reader should be better able to:

  1. Recall both the significance of ergonomics in minimally invasive surgery and the symptoms associated with musculoskeletal disorders.
  2. Critically appraise the ergonomics of one’s own surgical work environment.
  3. Anticipate or intervene in the occasion of experiencing physical fatigue or musculoskeletal disorders.

The laparoscopic approach has become standard for many surgical interventions due to its benefits compared with open surgery, which include less postoperative pain, faster recovery, shorter hospital stay, and improved cosmetic results.[1–3] Widespread implementation of laparoscopic procedures has led to increased studies of ergonomics in surgery. The field of ergonomics deals with the design and evaluation of job tasks, products, and environments to improve their compatibility with people’s needs, abilities, and limitations. In particular, physical ergonomics focuses on human anatomical, anthropometric, physiological, and biomechanical characteristics as related to physical activity.[4]

The field of minimally invasive surgery (MIS) is continuously evolving. Newer techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), have greater benefits for the patient,[5,6] but may increase the physical workload for the surgeon.[7–9] On the contrary, robotic approaches have been introduced. Debates surrounding robotic surgery mainly focus on the costs and patient benefits. However, another important issue is that robotic approaches may provide ergonomic benefits to the surgeon—enabling the surgeon to operate from a seated posture, and allowing more degrees of freedom for instrument movement and 3D vision.[10,11]

Several ergonomic studies reveal that during laparoscopic surgery, surgeons face multiple constraints that directly expose them to risk factors for developing musculoskeletal disorders (MSDs).[12–14] These risk factors include static body posture, repetitive upper extremity movements, and force exertion from adverse positions. Moreover, the workload is increased by the high level of task precision and time pressure. Physical demands differ between open and laparoscopic surgery and comparative studies have reported higher prevalences of physical complaints for laparoscopic surgeons.[15–17] Recent studies report MSD prevalence rates of 73% to 88% among specialists in MIS.[18–20] Relative to the general population, these numbers are excessively high. The Fourth European Survey on Working Conditions presents the prevalences of several MSDs, reporting a 24.7% prevalence of backache, 22.8% prevalence of muscular pain, and 23% prevalence of neck and shoulder pain.[21] A US-based study of a large occupational population reported a 20.8% prevalence of lower back pain.[22] MSDs develop gradually and can affect different parts of the musculoskeletal system, including muscles, joints, and nerves. Laparoscopic surgeons mainly report issues involving their neck, back, shoulders, wrists, and thumbs. Symptoms associated with these MSDs predominantly include fatigue, pain, stiffness, and numbness. Such symptoms can affect task accuracy,[23,24] potentially having an indirect impact on patient safety, which is the main priority in surgery.

In our present systematic review, the primary objectives were to determine the overall prevalence of MSDs among surgeons performing minimally invasive abdominal surgery, and to determine whether MSD prevalence varies according to body region and minimally invasive surgical method. The secondary objectives were to identify how MSD prevalence among surgeons impacts surgical performance, and to identify additional risk factors beyond the general ergonomic risk factors. Our present findings will provide insight into the contemporary magnitude and characteristics of MSDs among surgeons, which will help to design interventions, increase awareness, and to develop recommendations for clinicians and medical technicians.[25]


To summarize the overall MSD prevalence among surgeons performing MIS, we conducted a systematic review following the PRISMA guidelines. The search strategy was developed by CA, AdM, and TN in consultation with a research librarian at the Radboud University Library. On April 15 2016, we performed a search in PubMed, EMBASE, the Cochrane Library, Web of Science, CINAHL, and PsychINFO. The following search terms were used (as Medical Subject Headings and Title/Abstract words): “Human Engineering” OR “ergonomics” OR “human factors” OR “occupational health” OR “workload” AND “surgical procedures, minimally invasive” OR “minimally invasive surgery” OR “minimal access surgery” OR “laparoscopy” OR “endoscopy” OR “Surgery, Computer-Assisted” OR “Robotics.” Appendix 1, includes the full search strategies per database. We set no limits regarding year of publication, language, or publication status and we applied no other additional filters after running the search in the consulted databases.

Our present review focused on MIS performed in the abdominal cavity—including general, gynecological, and urological surgery. This limitation was applied because these specializations entail similar task-physical and environmental characteristics and, therefore, carry similar risk factors for developing physical complaints. For inclusion, studies had to address physical ergonomics as a determinant, report the prevalence of MSDs (or physical complaints) as a study outcome, and be published as full-text articles in a peer-reviewed journal.

All studies identified in the initial database search were independently reviewed by 2 researchers (CA and AdM). First, the titles and abstracts were screened to identify all articles related to physical ergonomics in MIS. Next, the full-text articles were obtained to determine eligibility for final inclusion in the synthesis. Disagreements were discussed with a third researcher (TN), and resolved by consensus. Finally, the references of the included articles were checked for additional articles of interest.

We recorded the following data from the included studies: year of publication, population/sample size/response rate, type of surgery, applied questionnaire, and primary and other relevant outcome measures. The primary summary measure was the reported prevalence of physical complaints. Secondary summary measures included predictors for symptom development and impact on surgical performance.

To evaluate the conduct of the included studies, we used the 22-item Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.[26,27] Each reviewed article was assessed for all 22 items with 1 point given for each successfully addressed item, and a total score calculated as the sum of all items. Finally, we calculated the average score for all reviewed articles.

Finally, we performed random effects meta-analyses for both overall prevalence of physical complaints and body part specific prevalence. We calculated exact binomial confidence intervals (CIs) for the individual studies, and performed an arcsine transformation of the proportions for the meta-analyses. We expected to find high heterogeneity due to differences in the utilized questionnaires (validated or not validated), in the MSD definitions, and in the study time frames. Therefore, we pooled the individual prevalence rates using the Hartung-Knapp-Sidik-Jonkman (HKSJ) method for random effects.[28] Heterogeneity was measured based on I2 and prediction intervals. Analyses were conducted in R (version 3.0.1; R Core Team 2012), using the meta package.[29]


The database search identified 7844 articles, of which 345 were primary research articles addressing physical ergonomics in MIS. Cross-reference checking identified 4 additional articles. Evaluation of full-text manuscripts led to the final inclusion of 35 studies. Figure 1 shows the PRISMA flow chart with detailed information regarding the selection process.

Figure 1.

PRISMA flow diagram.

Study appraisal yielded an average STROBE score of 17.5 (range 11 to 20) out of 22. Efforts to address potential sources of bias were poorly explained in the method sections, with only 2 articles successfully fulfilling this item. In addition, 7 articles failed to report the sample size, and 13 articles did not address the study limitations.

All included articles described survey studies, mainly using self-composed questionnaires. Four surveys reported integration of the Standardized Nordic Questionnaire for Musculoskeletal Symptoms[30] (NMQ) or a modified version.[31–34] Five surveys[25,35–38] integrated the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) ergonomic questionnaire, as developed by the SAGES Ergonomic Task Force.[39] To some extent, all studies subdivided the involved body regions, or enabled the respondents to describe the affected body parts. The articles widely differed in the terminology used for MSDs (eg, musculoskeletal symptoms, discomfort, injuries, or problems) and in the descriptors used to characterize the nature of the MSDs (eg, pain, numbness, stiffness, and fatigue). Moreover, the time period for occurrence of complaints ranged from a point prevalence (during or immediately after surgery), to a 12-month prevalence, to having ever experienced symptoms. The marked duration or emergence of musculoskeletal symptoms also varied from intraoperatively; shortly after surgery; up to recurrent, persistent, or chronic.

Response rates ranged from 6.1% to 100%, with an average of 40.2%. Overall, the reviewed studies included 7112 respondents who were mainly laparoscopic surgeons who performed procedures in general surgery, gynecology, and urology in both adult and pediatric patients. Three studies also included a subset of respondents (N = 378) that were (scrub) nurses, general physicians, anesthesiologists, or orthopedists.[13,40,41] Where possible, data from those respondents were excluded from our meta-analyses.

Table 1 provides an overview of included studies with itemized primary and other relevant outcomes. Of the included articles, 26 reported an overall MSD prevalence among surgeons performing any type of minimally invasive abdominal surgery, which ranged from 20% to 100% with an average of 74%, and a 95% CI of 65 to 83 (Figure 2).[13,14,16–20,25,32–34,37,38,41–53] We found high inconsistency across the study results, with an I2 value of 98.3%. Assuming that all nonresponders had never experienced physical complaints, the overall percentage would be 22% (95% CI 16–30). Among the laparoscopic surgeons with MSDs, the rate of chronic pain ranged from 10.8% to 51.5% with an average of 27% (95% CI 7–54).[16,18,19,32,53] The remaining 9 reviewed studies did not report an overall MSD prevalence, but rather reported MSD prevalence rates for specific body parts.[31,35,36,40,54–58] The body parts most commonly affected with discomfort or pain were the neck with 53% (95% CI 42–63),[14,16–18,20,25,31–34,36,40,41,43,47,49,51,53,54,56,57] back with 51% (95% CI 34–68),[14,17,18,25,36,43–45,47,49,53,54,56,58] shoulders with 51% (95% CI 41–60),[14,17,18,20,31,32,34,36,43,44,47,49,51,53,55–57] and hands with 33% (95% CI 14–55).[18,36,43,51,53,56] The inconsistency of the above-reported prevalence rates across studies was similar to that of the overall MSD prevalence.

Figure 2.

Overall MSD prevalence.

Seven studies, including 1852 respondents, reported the prevalence of physical complaints related to robotic surgery.[16,17,32,33,46,48,54] These studies reported a 56% (95% CI 32–78) overall prevalence of complaints associated with robotic surgery.[16,17,32,33,48] Considering the defined time-frames in these studies, 52.8% of respondents reported ever experiencing physical discomfort,[32,33,48] and 50.4% of surgeons reported complaints or discomfort during robotic surgery.[16,17,33] Franasiak et al[32] and Plerhoples et al,[16] respectively, reported 11.9% and 5% rates of chronic or persistent strain due to robotic surgery. Robotic surgery was most commonly related to discomfort in the neck and in the hand/wrist region, including thumbs and fingers. On the basis of ergonomic considerations, respondents preferred the robotic operative modality compared with either open or laparoscopic surgery,[32,54] and expressed that robotic surgery can be helpful for improving ergonomics.[18,55] Accordingly, Plerhoples et al[16] reported that among MSD sufferers, 8.3% attribute their physical complaints to robotic surgery, 36.3% to open surgery, and 55.4% to conventional laparoscopic surgery. Moreover, the difference in MSD prevalence is reportedly dependent on the body region.[16,17,34,55] Another 3 studies specifically determined the overall percentages of physical complaints during or after open surgery, reporting rates of 56.5%, 65%, and 85.4%.[16,17,55] Among the 5 reviewed studies that reported prevalence numbers for both open and laparoscopic surgery, all showed a higher prevalence of complaints in laparoscopic surgery than open surgery.[16,17,54–56]

Four studies reported that a substantial number of respondents (range 16.6% to 34.8%) believed that their physical complaints affected their surgical performance or activity.[31,41,44,55] Between 6.7% and 17% decreased their surgical practice (caseload) due to their physical complaints.[18,31,34] Park et al[19] reported that 40% of respondents ignored their physical complaints during surgery. Szeto et al[34] found that 35.6% of respondents always worked through pain so that the quality of their surgical work would not suffer. Bagrodia and Raman[54] and Plerhoples et al,[16] respectively, reported that 25% and 30% of surgeons gave some consideration to their own physical discomfort when choosing an operative approach.

The reviewed studies reported several risk factors for MSD development. Sutton et al[52] specifically addressed sex as a risk factor, showing that female surgeons were significantly more likely to receive treatment for their hands and reported significantly more cases of shoulder discomfort, even with correction for glove size. Four other studies reported sex as a risk factor, showing that women were more likely to develop MSDs.[18,31,48,51] Berguer and Hreljac[42] specifically addressed the relationship between hand size and difficulty using instruments, finding that surgeons with a small glove size reported greater difficulty using all laparoscopic instruments than surgeons with a medium or large glove size (P < 0.001). Franasiak et al[18] found that increased pain symptoms were significantly associated with glove size; however, the majority of respondents in this study stated that their instruments fit “just right” (70.8% to 84.8%, depending on type of instrument).

Overall, 12 studies examined the constraints of laparoscopic instruments.[13,18–20,36,40,42,43,45,47,50,52] Three of these studies directly assessed the surgeons’ perspectives regarding handle design. Handle design was reported as a cause of physical complaints by 49% of respondents in the study of Sari et al,[20] 74.4% in Park et al,[19] and 83% in Matern and Koneczny.[47] More specifically, Matern and Koneczny[47] reported that 36% of surgeons complained about pressure areas, 26% about neuropraxia, and 57% about uncomfortable posture due to instruments. Cass et al[43] found that difficulty manipulating instruments was a significant causative factor in injury of disc prolapse. Moreover, improper positioning of the surgical setup—including monitor height and position, table height, and use of foot pedals—affected the surgeons’ comfort and was indicated as a risk factor for MSD development in 8 studies.[13,14,19,20,36,40,47,52]

Eight studies assessed the workload in terms of caseload or number of hours spent performing MIS. The findings on this topic were somewhat ambiguous. Six studies reported that increased laparoscopic workload was significantly related to physical complaints.[19,42,43,46,51,53] In contrast, McDonald et al[48] and Franasiak et al[18] identified no relationship between caseload and physical complaints for conventional laparoscopic procedures. However, the latter study reported that the number of cases per day and case length were significant risk factors for MSD development in robotic surgery. Plerhoples et al[16] found that surgeons with more laparoscopic cases (P < 0.0001), greater annual laparoscopic volume (P < 0.0001), or with longer career durations (P = 0.03) were more likely to attribute their pain to the laparoscopic modality.

Ten studies reported data regarding experience and age. Four studies found that less experienced surgeons were more likely to report physical complaints.[18,20,36,56] Accordingly, 4 studies reported that younger age was associated with higher rates of physical complaints.[18,20,53,56] In contrast, Stomberg et al[51] and Cass et al[43] reported that injury risk increases with age. Plerhoples et al[16] identified no relationship between age or experience and physical complaints. McDonald et al[48] reported that younger surgeons were more likely to report symptoms; however, this association disappeared with correction for sex. Park et al[19] found that age and years of practice were not correlated with physical complaints. However, they identified a significant correlation between case volume and symptoms in the neck, right hand, upper extremities, and lower extremities (all P < 0.05). They concluded that the number of cases performed per year was a stronger predictor of physical complaints than either age or years in practice.



Our present systematic review was designed to evaluate the available literature regarding physical complaints and MSDs among surgeons performing laparoscopy. We found high inconsistency across studies, along with a low overall response rate. MSD prevalence among surgeons was found to be 74% (95% CI 65–83). However, if all nonresponders were assumed to have never experienced MSDs, this prevalence was adjusted to 22% (95% CI 16–30).

Despite early reports of the physical drawbacks of laparoscopic surgery in the late 1990s,[39,56] little has improved regarding the ergonomics and physical workload for surgeons. This may be partly because the laparoscopic approach has become the preferred approach from the patients’ perspective.[59–61] Furthermore, there has been clear development of greater surgical specialization. Consequently, subgroups of surgeons may spend a relatively high percentage of their daily activities performing laparoscopic procedures. Another issue is that a higher surgical caseload might actually be beneficial for several patient-reported outcome measures.[62–64] Altogether, these trends in the field have led to an overall rising caseload of laparoscopic procedures, with a correspondingly higher chance of surgeons developing MSDs.[16,18,32,34,43,48,51]

One might consider physical complaints to be a “part of the job.” However, when such complaints appear to negatively influence the quality of surgical care, it becomes a matter of professional ethics. Several reviewed studies described surgeons who believed that their surgical performance was negatively affected by their own injury or pain.[31,41,44,55] In 2 studies, respondents expressed that their physical complaints influenced their choice of operative approach.[16,54] This suggests that in some cases, patients may not receive the best clinical care available due to their surgeon’s physical condition. Szeto et al[34] found that 35.6% of respondents reported almost always “working through pain so that the quality of their work would not suffer.” However, it remains unclear whether physical complaints really impact surgical outcomes. Especially in cases of laparoscopic hysterectomy or (hemi)colectomy—where important steps are taken late in the procedure—the physiological process underlying fatigue of the surgeon’s upper extremity may play a role in complaint occurrence. Sari et al[20] found that no respondents reported any surgical complications due to their own fatigue or physical complaints; however, this could have been influenced by surgeons’ reluctance to admit to such occurrences.

There remains a need for further clarification of the difference in physical complaints between the sexes. On average, female surgeons have smaller hands and glove size. Almost all laparoscopic instruments have a “one size fits all” handle, and previous studies report that such handles are less comfortable for surgeons with small glove sizes.[18,42,52] This could partially explain the higher rates of physical complaints in the upper extremity among women. This finding could also be influenced by anatomical muscular differences between the sexes. Moreover, differences in interplay between working life and private circumstances may be of influence.[65] Furthermore, it is possible that male surgeons are less aware of their complaints or more reluctant to admit that they experience physical complaints. The fact that less-experienced surgeons report more complaints justifies an enhanced focus on ergonomics during surgical residency. Junior surgeons are less familiar with laparoscopic procedures and may intrinsically experience higher mental and physical stress levels. Consequently, their main intraoperative focus will be on the surgical procedure, with less attention paid to their own physical status, surgical setup, or other ergonomic conditions. Implementing an ergonomic module for surgical residents will likely enhance their awareness of surgical conditions as a whole.

One reported benefit of the implementation of robotic surgery is that it offers superior ergonomics. However, our present review showed that sitting in the console still has its limitations, which is supported by evidence in several prior studies.[66,67] Among robotic surgeons, MSD prevalence is the highest in the neck, with up to 35% of robotic surgeons experiencing pain, stiffness, or numbness in this area.[16,17,32,33,46,54] Studies in pathologists and cytotechnologists demonstrate that prolonged use of conventional microscopes is a risk factor for developing (chronic) musculoskeletal injuries, including shoulder, neck, back pain, and fatigue.[68,69] Robotic surgery involves a similar body posture as working with a microscope. Thus, robotic surgeons may benefit from existing knowledge regarding ergonomic guidelines for prolonged microscope use.

This review has several potential limitations. First, the studies used different questionnaires and definitions of MSDs. The common use of terms, such as physical complaints, fatigue, numbness, and pain, contributed to overall inconsistency among studies. The appropriateness of pooling results obtained from various more-or-less self-composed questionnaires is scientifically debatable. However, this was regarded as the least objectionable option available for use in our present review. Furthermore, the STROBE score is not a formal tool for measuring methodological study quality, but was used in our study as a checklist for reporting several outcomes and biases. Another limitation is the possibility of recall bias. All reviewed studies were retrospective analyses, and it is possible that not all respondents were able to clearly report their physical condition. There is also a potential for selection bias, in that the respondents who had experienced physical complaints may have been more eager to complete a questionnaire on this topic. Consequently, the percentage of surgeons reporting physical complaints may be an overrepresentation within the whole population of laparoscopic surgeons. It is known that survey studies among physicians are prone to low response rates.[70] However, it is possible that those surgeons who did not experience physical complaints were reluctant to respond to the questionnaires. Therefore, we recalculated the overall prevalence rate in case the nonresponders had never experienced physical complaints. Moreover, not all studies reported whether the surgeons were asked for their opinion on whether their physical complaints were more or less directly related to MIS. Future prospective studies must focus on the distinction between any MSD versus clinically relevant MSDs with regard to patient safety.

In conclusion, the findings of this systematic review indicate that the MSD prevalence among surgeons performing MIS is likely higher than is commonly acknowledged, warranting future well-designed studies. This matter is clinically relevant, as kinesiology studies reveal that fatigue and MSDs can impact psychomotor performance. Alongside epidemiological research, future studies should also focus on evaluating surgical tasks, environment, and instrument design[40,42,52,71] Interventions, such as formal ergonomic training,[19,25,32] warm-up before surgery,[72,73] and microbreaks during surgery,[74,75] may improve surgeons’ physical health and warrant further scientific evaluation.


#Los #suplementos no evitan las #fracturas en adultos sanos de edad avanzada

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Un metanálisis de múltiples estudios aleatorizados no respalda el uso de suplementos de calcio o vitamina D, o su combinación, para reducir el riesgo de fracturas de cualquier tipo en adultos sanos de edad avanzada, reafirman investigadores chinos.[1]

“El aumento de las cargas sociales y económicas por fracturas relacionadas con osteoporosis en todo el mundo origina que la prevención de estas lesiones sea un objetivo de salud pública importante”, escriben el Dr. Jia-Guo Zhao, del TianJin Hospital, en Tianjin, China, y sus colaboradores.

“Pero los resultados de este metanálisis demostraron que el calcio, el calcio más la vitamina D, y los suplementos de vitamina D por sí solos, no se relacionaron en grado significativo con una menor incidencia de fracturas de cadera, no vertebrales, vertebrales, o totales, en adultos de edad avanzada de la población”.

“En general, estos resultados fueron consistentes, independientemente de dosis de calcio o vitamina D, género, antecedente de fracturas, ingesta de calcio alimentario, y concentraciones séricas iniciales de 25-hidroxivitamina D”, concluyen los autores.

El estudio fue publicado en el número del 26 de diciembre de Journal of the American Medical Association.

El metanálisis constó de 33 estudios clínicos aleatorizados que incluyeron a 51.145 participantes mayores de 50 años. “En 14 estudios se compararon los suplementos de calcio con placebo o ningún tratamiento”, informan los investigadores. Observaron una reducción del riesgo relativo (RR) de 53% en las fracturas de cadera con los suplementos de calcio (RR: 1,53; IC 95%: 0,97 – 2,42), pero esta no fue significativa, y la diferencia en el riesgo absoluto fue de 0,01, en comparación con placebo, o ningún tratamiento.

Asimismo, la reducción del riesgo relativo con suplementos de calcio y las fracturas no vertebrales fue de 0,95 (IC 95%: 0,82 – 1,11), con una diferencia en el riesgo absoluto de -0,01. De nuevo, esta no fue significativa en comparación con placebo, o ningún tratamiento. Tampoco se observó alguna relación significativa entre el riesgo de fracturas vertebrales, con reducción del riesgo relativo de 0,83 (IC 95%: 0,66 – 1,05), y una diferencia en el riesgo absoluto de -0,01, o en las fracturas totales, con una reducción del riesgo relativo de 0,88 (IC 95%: 0,75 – 1,03), y una diferencia en el riesgo absoluto de -0,02, en comparación con placebo, o ningún tratamiento.

“En 17 estudios se compararon los suplementos de vitamina D con un placebo, o ningún tratamiento”, continúan los investigadores. Una vez más se observó una ligera reducción de 21% en el riesgo relativo de fracturas de cadera con los suplementos de vitamina D, en comparación con placebo, o ningún tratamiento (RR: 1,21; IC 95%: 0,99 – 1,47), con una diferencia en el riesgo absoluto de 0,00.

Sin embargo, la diferencia entre el grupo que recibió suplementos, y quienes no los tomaron, tampoco fue significativa, puntualizan los investigadores. Tampoco se observó una reducción significativa en las fracturas no vertebrales con los suplementos de vitamina D (RR: 1,10; IC 95%: 1,00 – 1,21), con una diferencia en el riesgo absoluto de 0,01. Lo mismo fue aplicable para las fracturas vertebrales y totales, en comparación con placebo, o ningún tratamiento, con un riesgo relativo de fracturas vertebrales de 0,97 (IC 95%: 0,54 – 1,77), y 1,01 para las fracturas totales (IC 95%: 0,87 – 1,17), con una diferencia en el riesgo absoluto de 0,00 para ambos criterios de valoración relacionados con las fracturas.


#Arthritis in #Chikungunya Patients Not Due to Persistent Virus

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Chikungunya virus (CHIKV) infection, a mosquito-borne disease reported in the Americas in 2013, leaves about one quarter of those infected with persistent arthritis, according to data from the Chikungunya Arthritis Mechanisms in the Americas (CAMA) study. The joint symptoms, however, do not appear to be associated with persistent infection, suggesting it is safe to treat patients with regimens used for other types of inflammatory arthritis.

Chronic joint pain after CHIKV infection has been reported previously in prior studies, but the frequency was unclear, with estimates ranging from 30% to 70%. Therefore, Aileen Y. Chang, MD, MSPH, from the Department of Medicine at George Washington University in Washington, DC, and colleagues conducted a cross-sectional follow-up of a prospective cohort of 500 patients who had been clinically diagnosed during the 2014 to 2015 Columbian epidemic.

The patients, referred for the study by primary care providers, had clinically suspected CHIKV, defined as fever greater than 38°C, severe joint pain or arthritis, acute onset of erythema, and residing or having visited an area with evidence of CHIKV transmission.

Of these subjects, 485 were serologically confirmed as having CHIKV and responded to baseline questions regarding joint pain. The most commonly affected joints were wrists, ankles, and fingers, and initial joint pain had lasted a median of 4 days. The authors note there were no significant increases in rheumatoid arthritis-associated markers or in C-reactive protein in subjects with CHIKV-associated arthritis.

With a median follow-up of 20 months, 25.4% of participants reported in a telephone interview that they had persistent joint pain. Factors associated with persistent pain included initial symptoms of headache or joint pain, 4 or more days of initial symptom, 4 or more weeks of initial pain, missed work, missed normal activities, and college graduate status. At follow-up, most patients had only one swollen joint, but also had tenderness in three more joints, with a mean global pain score of 47.

“The finding of chronic joint pain in one fourth of the patients infected with CHIKV approximately 2 years after initial infection has important implications for prediction of the magnitude of disability and health system costs after the Latin American epidemic,” the authors write in an article published online December 20 in Arthritis & Rheumatology. “Prior predictions had over-estimated the expected frequency of CHIKV-related joint pain in Latin America indicating 48% of CHIKV-infected people were predicted to have chronic chikungunya arthritis 20 months after acute infection.”

The authors explain in an accompanying article published at the same time that although small studies have shown apparent benefit from treating CHIKV with antivirals such as ribavirin or immunosuppressants such as methotrexate, hydroxychloroquine, etanercept, adalimumab, or sulfasalazine, large-scale clinical studies will require deeper understanding of CHIKV pathophysiology. “If persistent CHIKV infection is responsible for ongoing arthritis, immunocompromising disease modifying agents may be improper and potentially dangerous treatments. Alternatively, if CHIKV does not persist in the joint, then evaluation of immunomodulating arthritis agents could be useful,” they write.

To address that question, the researchers also performed a cross-sectional analysis of synovial fluid from 38 CHIKV-infected subjects with chronic arthritis and 10 location-matched control patients who were CHIKV-negative and did not have arthritis. The researchers tested the synovial fluid for CHIKV, viral RNA, and viral proteins, using viral culture, quantitative reverse transcription polymerase chain reaction, and mass spectrometry, respectively. All three assays were negative, indicating that the joint pain is not a result of persistent viral infection.

Furthermore, plasma cytokine/chemokine concentrations did not differ significantly between cases and controls, which also supports that conclusion.

The researchers conclude, “This finding suggests that CHIKV may cause arthritis through induction of potential host autoimmunity suggesting a role for immunomodulating medications in the treatment of CHIKV arthritis or that low-level viral persistence exists in synovial tissue only that is undetectable in synovial fluid.”

The authors have disclosed no relevant financial relationships.

Arthritis Rheum. Published online December 20, 2017. Chronic joint pain abstract, Arthritis abstract