ACKNOWLEDGEMENTS The authors thank Sanofi-Aventis(r) for donating the medication for this study. Footnotes quality control Study conducted at LIM 41 – Laboratory of Medical Investigation of the Musculoskeletal System and in the Group of Osteometabolic and Degenerative Diseases of the Department of Orthopedics and Traumatology of the School of Medicine of Universidade de S?o Paulo. Citation: Zelada F, Almeida AM, Pailo AF, Bolliger Neto R, Okazaki E, Rezende MU. Viscosuplementation in patients with hemophilic arthropathy. Acta Ortop Bras. [online]. 2013;21(1):12-17. Available from URL: http://www.scielo.br/aob.
Chronic low back pain is one of the main complaints of patients with musculoskeletal disorders. It is defined by the presence of pain in the lumbar region lasting for more than 7-12 weeks.

1 It entails restriction of the capability for work, limitation for social activities, emotional problems 2 and reduced quality of life. 3 Chronic low back pain is frequently associated with depression. 4 Between 16.4 and 73.3% of the patients with chronic low back pain present depression. 5 The presence of depression is associated with the greater intensity and persistence of pain, 6 greater incapacity, 2 , 7 higher economic cost 2 and more adverse life events. The literature investigated did not produce any trials that were aimed at studying the impact of depression on the characteristics of chronic low back pain and on the fear of movement (kinesiophobia). The aim of the present study was to describe characteristics of pain, kinesiophobia and quality of life in patients with chronic low back pain associated with depression, in comparison to patients with chronic low back pain without depression.

METHOD This is a cross-sectional observational study, conducted in the outpatient physiotherapy section of a state government institution, on patients diagnosed with chronic low back pain. The study was carried out in the period from August 2008 to August 2009. The participants who agreed to take part in the study signed the informed consent form. The project was approved by the Institutional Review Bureau (Report no. 307/08). The inclusion criteria were: patients of both sexes, from 18 to 60 years of age, diagnosed with chronic low back pain at least three months previously.

Patients with neurological diseases (cerebrovascular accident, cerebral palsy and Parkinson’s disease), patients who had suffered any type of recent fracture, patients who were in a postoperative process of any nature, those with important acute diseases in physiotherapeutic treatment, AV-951 patients with chronic cancer pain and patients with chronic low back pain with nonmusculoskeletal causes were excluded. A total of 193 individuals, referred by orthopedists for outpatient physiotherapy treatment, were included in the study. The interviews were held by a single investigator, previously trained to apply the instruments.

Despite the introduction of new treatment options and techniques, treatment of four-part fractures is still controversial. 3 Conservative measures are not appropriate for displaced fractures, because they lead to painful mal-union and, unstable or stiff shoulder in most cases. In elderly patients with selleck compound osteoporotic bones and a sedentary life style, the results of the conservative or surgical treatment are closely similar to each other and therefore the latter should not be routinely indicated. 4 In younger active patients, with good quality bone stock, surgical treatment is preferred, thus permitting early rehabilitation measures and leading to better functional results. 5 Minimal osteosynthesis techniques have been developed for the four-part fractures in order to avoid the excessive soft tissue damage of extensive surgical exposures and to avoid compromise of the blood supply to the entire bone.

6 Satisfactory results have been reported with the use of such techniques, particularly concerning pain relief and function. Avascular necrosis of the head dome fragment is a frequent complication, regardless of the type of treatment and fixation technique, and most authors agree that it is quite often an asymptomatic condition, not requiring any further surgical measure. 1 , 6 – 8 Percutaneous pinning, bone sutures, tension band wiring, intramedullary nailing, fragment specific screw fixation, and various types of plates (T-shaped, angled and blocked plates) are among the proposed fixation techniques for such complex fractures, but there is no consistent evidence about the best alternative for active patients.

1 , 5 Actually, the mechanical resistance of different fixation techniques has been studied, but the results obtained in different studies do not authorize the general and unrestricted use of such techniques in clinical situations, considering the different methodology used in each study. 5 , 9 , 10 Therefore, it is our opinion that the minimal fixation for the four-part fractures of the proximal end of the humerus is still a controversial issue regarding the mechanical behavior of different types of fixation, and that deserves further investigation. In the present study, a new biomechanical model involving an aluminum scapula and synthetic humeri was developed to allow closer-to-real biomechanical essays.

The synthetic humeri were fixed onto the aluminum scapulae by means of leather straps corresponding to the supraespinatus, infraespinatus and subscapularis tendons and lower capsula, and four different techniques for minimal fixation of the four-part fractures of the proximal end of the synthetic humeri have Dacomitinib been used. MATERIAL AND METHODS The first step of the investigation was to design a close to real model of the shoulder joint. A plastic human scapula and humeri (Nacional Ossos(r), Ja��, Brazil*), currently used for osteosynthesis drills, were used.

, West Somerville, NJ) be applied at the end of every procedure to assist Ruxolitinib with postoperative hemostasis. Just this year, in response to several reports of post-circumcision staphylococcal infections arising most likely from poor sterilization techniques,2 many hospitals around the country have further refined their circumcision procedure policies. They now require that all persons in the room are to be gowned, masked, and gloved. Vials of lidocaine may be used only once and then must be discarded. Leg restraints may no longer be cleaned, but must be disposed of. Parents are barred from observing the procedure, and only 1 infant can be in the procedure room at a time. Whether male newborn circumcision is an appropriate procedure to start with is a discussion for another time.

The issue under review here is not the circumcision procedure itself, but its cost. Although the actual circumcision technique has probably changed little since the time of Abraham, its cost has exploded (even when adjusted for early Semitic currency inflation). However well intended, each refinement adds additional and incremental costs to the procedure. Sterile steel instruments cost more than a sharpened stone. Local anesthesia adds cost. Surgicel adds cost. One-on-one nursing staff need to be reimbursed for their time, which adds cost. Disposable gloves, gowns, masks, and leg straps add cost. Reduced efficiency adds cost. And then there are the exorbitant indirect expenses such as malpractice costs. Despite these comments, looking at the procedure today, it is difficult to see where significant cost savings can be achieved.

Withholding anesthesia from newborn infants is no longer appropriate. Local nurses�� unions determine staffing requirements, and State Departments of Public Health are responsible for issuing guidelines about sterile technique with a view to optimizing patient safety. And the cost of a small piece of Surgicel seems reasonable to reduce bleeding complications, however rare they may be. Although a zero-tolerance policy toward adverse events is laudable, such an approach has to be tempered by reasonable judgment. As the rising cost of healthcare in the United States takes center stage, clinical and political leaders have some difficult choices to make. What is clear is that the current system is not sustainable.

Resources are not unlimited, and difficult and unpopular decisions will have to be made to determine where we as a society are willing to sacrifice quality and what impact such restrictions will have on the public at large. As illustrated above for newborn circumcision, costs can easily get out of control when catch phrases such as ��patient safety�� are used to trump common sense and cost-containment efforts. Changes in practice should AV-951 be instituted only once they have been shown to offer both an improvement over existing practices and to be cost effective.