94 patients (96 knees) had a two-stage reimplantation for treatment of an infected total knee arthroplasty. All patients were treated with an interval antibiotic-loaded static cement spacer and had antibiotic-loaded bone cement for prosthesis fixation at the time of reimplantation. The purpose of this study was to assess the long-term risk of reinfection and the mechanical durability of these reimplantation arthroplasties. Patients were followed up for a median of 7.2 years (range, 2.5-13.2 years). At final followup, 15 knees (16%) had required reoperation. Nine knees (9%) had component removal for reinfection and six knees (6%) were revised for aseptic loosening. The median time to reoperation for reinfection was 1 year (range, 0.1-9.8 years). The risk of recurrent infection was not correlated with the type of organism, patient demographics, or method of prosthesis fixation at reimplantation. The survivorship free of implant removal for any reason was 90% (confidence intervals, 83.9-96.4%) at 5 years and 77.3% (confidence intervals, 65.5-89.6%) at 10 years. The survivorship free of implant removal for reinfection was 93.5% (confidence intervals, 88.5-98.7%) at 5 years and 85% (confidence intervals, 73.8-96.3%) at 10 years. Survival free of revision for mechanical failure (aseptic loosening or radiographic loosening) was 96.2% (confidence intervals, 92-100%) at 5 years and 91% (confidence intervals, 80.8-98.3%) at 10 years. These results suggest that the high likelihood of early success after two-stage reimplantation of an infected TKA is well maintained throughout long-term followup, with a modest rate of late recurrent infection or mechanical implant failure.A two-stage reimplantation protocol for the treatment of the infected total knee arthroplasty (TKA) originally was proposed by Insall et al. 10 Their report of 11 knees noted initial eradication of infection in all knees, but one knee eventually had reinfection develop with a different organism because of hematogenous spread. For the past two decades, many investigators adopted this two-stage protocol but also augmented this treatment approach with the use of antibiotic-loaded bone cement for delivery of local antibiotics. 1,7,9,14,16 The use of antibiotic-loaded bone cement for prosthesis fixation at the time of reimplantation has been shown to lower considerably the risk of reinfection. 6 In contrast, the use of antibiotic-loaded cement block spacers or the use of antibiotic-loaded mobile articulating spacers has not been shown definitively to reduce the risk of reinfection, but their use does facilitate the ease of the reimplantation procedure. 1,4,6,9 Short-term cure rates of infection associated with modern techniques of reimplantation are approximately 90%. 16 Most reports have focused primarily on the cure rate of infection at short-term followup, but little is known about the long-term reinfection-free survival or the mechanical durability of the reimplanted prostheses. 5 The purpose of the current study was to evaluate the mid-term to long-term res...
BackgroundOral health education (OHE) in schools has largely been imparted by dental professionals. Considering the substantial cost of this expert-led approach, the strategies relying on teachers, peer-leaders and learners themselves have also been utilized. However the evidence for comparative effectiveness of these strategies is lacking in the dental literature. The present study was conducted to compare the effectiveness of dentist-led, teacher-led, peer-led and self-learning strategies of oral health education.MethodsA two-year cluster randomized controlled trial following a parallel design was conducted. It involved five groups of adolescents aged 10-11 years at the start of the study. The trial involved process as well as four outcome evaluations. The present paper discusses the findings of the study pertaining to the baseline and final outcome evaluation, both comprising of a self-administered questionnaire, a structured interview and clinical oral examination. The data were analyzed using Generalized Estimating Equations.ResultsAll the three educator-led strategies of OHE had statistically higher mean oral health knowledge (OHK), oral health behavior (OHB), oral hygiene status (OHS) and combined knowledge, behavior and oral hygiene status (KBS) scores than the self-learning and control groups (p<0.001). The mean OHK, OHS and KBS scores of the three educator-led strategies did not differ significantly. The peer-led strategy was, however, found to have a significantly better OHB score than the respective score of the teacher-led strategy (p<0.05). The self-learning group had significantly higher OHB score than the control group (p<0.05) but the OHK, OHS and KBS scores of the two groups were not significantly different.ConclusionsThe dentist-led, teacher-led and peer-led strategies of oral health education are equally effective in improving the oral health knowledge and oral hygiene status of adolescents. The peer-led strategy, however, is almost as effective as the dentist-led strategy and comparatively more effective than the teacher-led and self-learning strategies in improving their oral health behavior.Trail registrationSRCTN39391017
BackgroundRepetition and reinforcement have been shown to play a crucial role in the sustainability of the effect of Oral Health Education (OHE) programs. However, its relevance to school-based OHE imparted by different personnel is not depicted by the existing dental literature. The present study was undertaken to determine the effectiveness of the repeated and reinforced OHE (RR-OHE) compared to one-time OHE intervention and to assess its role in school-based OHE imparted by dentist, teachers and peers.MethodsThe study was a cluster randomized controlled trial that involved 935 adolescents aged 10-11 years. Twenty four boys’ and girls’ schools selected at random in two towns of Karachi, Pakistan were randomly assigned to three groups to receive OHE by dentist (DL), teachers (TL) and peer-leaders (PL). The groups received a single OHE session and were evaluated post-intervention and 6 months after. The three groups were then exposed to OHE for 6 months followed by 1 year of no OHE activity. Two further evaluations at 6-month and 12-month intervals were conducted. The data were collected by a self-administered questionnaire preceded by a structured interview and followed by oral examination of participants.ResultsThe adolescents’ oral health knowledge (OHK) in the DL and PL groups increased significantly by a single OHE session compared to their baseline knowledge (p < 0.05) and the increase was sustained over 6 months. Although one-time OHE resulted in a significant improvement in adolescents’ oral health behavior (OHB) related to the prevention of gingivitis in the two groups (p < 0.05), no significant change was observed in their behavior towards prevention of oral cancer. One-time teacher-led OHE was ineffective in improving adolescents’ OHK and OHB. The oral hygiene status (OHS) of the participants in all three groups did not change statistically after one-time OHE. The OHK, OHB and OHS indices increased significantly 6 months after RR-OHE than the initial scores (p < 0.001) irrespective of OHE strategy. Although the OHK scores of the DL and PL groups decreased significantly at 12-month evaluation of RR-OHE (p < 0.05), the said score of the TL group; and OHB and OHS scores of all three groups remained statistically unchanged during this period.ConclusionsThe repetition and reinforcement play a key role in school-based OHE irrespective of educators. The trained teachers and peers can play a complementary role in RR-OHE.
Fine-needle aspiration cytology (FNAC) is a widely practiced technique in the diagnosis of breast carcinoma, and it is the only diagnostic procedure performed before definitive treatment, at most institutions. While the histological grading of breast carcinoma has become routine in many centers worldwide, the cytopathological grading of breast carcinoma is not commonly used. Grading of breast carcinoma, while the tumor is still in vivo, would be the most ideal and desirable situation, as it would be helpful in the selection of patients for appropriate therapy. The objective of this study, therefore, was to devise a simple system for grading breast carcinoma, based on the cytological features alone. We reviewed 125 cases of breast carcinoma retrospectively, which were initially diagnosed by FNAC, with subsequent histopathological confirmation. These included 105 ductal, 6 lobular, 2 tubular, 1 papillary, and 1 medullary carcinoma. There was 1 ductal carcinoma in situ. Nine cases were rendered insufficient for grading. Thus 105 cases of ductal carcinoma (NOS) were evaluated for final cytological grading. Air-dried Diff-Quik-stained smears were reviewed at least twice independently by four histopathologists and were then compared with the original histological grades. Six cytological features used for grading were found to be statistically significant: cellular pleomorphism, nuclear size, nuclear margin, nucleoli, naked tumor nuclei, and mitoses. A scoring system based on these six essential parameters was used, to classify ductal carcinoma into three cytological grades, which showed close correlation with the established histological grades. In addition, two less consistent, but still important, features were the presence or absence of necrosis and stromal invasion. Another six parameters, including smear cellularity, degree of cell dispersion or clustering, lymphoplasmacytic infiltrate, presence of tubular structures, cytoplasmic appearance of the tumor cells, and smear background, were not statistically significant. However, these additional parameters were found helpful in assigning the correct grade, in cases with borderline scores. The concordance rate with histology was 100% for grade 1, 98% for grade 2, and 93% for grade 3.
The earliest attempt at classifying avascular necrosis of the femoral head was proposed by Ficat and Arlet in 1964 [2], before the advent of MRI. The purpose of the classification was to provide prognostic insight and compare treatment options. Ficat modified the classification to include invasive testing procedures and a preclinical, preradiographic stage in 1985 [1]. Since then the system has been modified a few times to include MRI findings, patient symptoms, modify the description of radiographic findings, and exclude the invasive testing procedures originally described [13, 17]. In a systematic review of the literature, Mont et al. [13] identified 16 different classification systems used to classify and describe avascular necrosis. Of these, the Ficat classification [1, 2] was the most frequently used system (63%), followed by the University of Pennsylvania system [18] (20%), the Association Research Circulation Osseous (ARCO) system [4, 15] (12%), and the Japanese Orthopaedic Association system [7] (5%). Purpose An ideal classification system should be practical, valid, reliable, and of prognostic importance. It also would help to choose between different treatment options and facilitate communication between researchers. This would form the basis for uniform reporting of results. There is controversy surrounding the classification of osteonecrosis of the femoral head and indications and success of the various treatment options in preservation of the femoral head [13]. The controversy surrounds the natural history of progression and whether the treatment more frequently preserves the contour of the femoral head than would occur without treatment. Lack of a universally accepted classification system makes it difficult to compare and analyze the data emanating from different centers. Osteonecrosis of the femoral head typically affects patients with a mean age in the middle thirties [11, 13], and for the majority of patients, leads to collapse of the femoral head if left untreated [13]. Spontaneous resolution of femoral head necrosis also has been reported among patients who have had renal transplants [9, 14, 16, 20]. Hip arthroplasty is not associated with expected longevity (72% 10-year survival in the Finnish registry for patients younger than 55 years) in this younger age group [3, 5, 10, 13]. Thus preservation of the femoral head is the objective of diagnostic and treatment strategies. A useful classification system would outline the criteria of early diagnosis. However, there is no specific radiographic appearance for Each author certifies that he or she, or a member of their immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
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