Comparison between tension band and cerclage with X-Plate and lag screws in treatment of comminuted patellar fractures

BackgroundComminuted patellar fractures are not rare, and the ideal treatment method remains controversial. The present study was conducted to evaluate effects and compare complications of two different methods used to treat comminuted patellar fractures.MethodsFrom March 2010 to August 2016, 102 cases of 34-C2 or 34-C3 comminuted patellar fractures were treated at our hospital, wherein patients received two different treatments: titanium cable tension band with cerclage method (group A) and intrafragmentary screws with X-shaped plating technique (group B). At follow-ups, articular step-off, range of motion (ROM), Lysholm scores, time of union, and complications were recorded and analyzed. Radiographic and clinical data as well as rate of complications were statistically analyzed.ResultsIn total, 87 patients were included in the final analysis (n = 47 in group A and n = 40 in group B). No significant differences were noted in terms of cost of implant, age, gender, rate of 34-C3 fractures, rate of layered inferior pole fractures, postoperative articular step-off and union time. At 2-year follow-up, average Lysholm scores, ROM and rate of complications were (89.0 ± 4.5), (122°±12°) and (27.7%) in group A and (90.2 ± 3.9), (124°±11°) and (17.5%) in group B, respectively, with no significant differences (p > 0.05). The mean time of surgery in group B was shorter than that in group A with significant difference (p < 0.05).ConclusionsTreatment using the intrafragmentary screws and plate method for amenable comminuted patellar fractures achieved similar complication rate and favorable functional outcomes at the 2-year follow-up, which was comparable to the titanium cable tension band with cerclage method. Thus, the intrafragmentary screws and plate method is effective, safe and convenient for 34-C2/C3 comminuted patellar fractures, especially appropriate for patients with layered fragments.     

Prognostic validity of the American joint committee on cancer eighth edition staging system for well-differentiated pancreatic neuroendocrine tumors

BackgroundThe American Joint Committee on Cancer (AJCC) made improvements for staging pancreatic neuroendocrine tumors (pNETs) in its 8th Edition; however, multicenter studies were not included.MethodsWe collected multicenter datasets (n = 1,086, between 2004 and 2018) to validate the value of AJCC 8 and other coexisting staging systems through univariate and multivariate analysis for well-differentiated (G1/G2) pNETs.ResultsCompared to other coexisting staging systems, AJCC 7 only included 12 (1.1%) patients with stage III tumors. Patients with European Neuroendocrine Tumor Society (ENETS) stage IIB disease had a higher risk of death than patients with stage IIIA (hazard ratio [HR]: 4.376 vs. 4.322). For the modified ENETS staging system, patients with stage IIB disease had a higher risk of death than patients with stage III (HR: 6.078 vs. 5.341). According to AJCC 8, the proportions of patients with stage I, II, III, and IV were 25.7%, 40.3%, 23.6%, and 10.4%, respectively. As the stage advanced, the median survival time decreased (NA, 144.7, 100.8, 72.0 months, respectively), and the risk of death increased (HR: II = 3.145, III = 5.925, and IV = 8.762).ConclusionThese findings suggest that AJCC 8 had a more reasonable proportional distribution and the risk of death was better correlated with disease stage.     

Discordance Between Clinical and Pathological Staging and Grading in Upper Tract Urothelial Carcinoma

IntroductionThis study aimed to evaluate the concordance in tumor stage and grade between ureteroscopic (URS) biopsy and radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC).Patients and MethodsRecords of 1,214 UTUC patients who had undergone URS biopsy followed by RNU were included. Univariable and multivariable logistic regression analyses were performed to identify factors contributing to the pathological upstaging.ResultsThe concordance between URS biopsy-based clinical and RNU pathological staging was 34.5%. Clinical understaging occurred in 59.5% patients. Upstaging to muscle-invasive disease occurred in 240 (41.7%) of 575 patients diagnosed with ≤cT1 disease. Of those diagnosed with muscle-invasive disease on final pathology, 89.6% had been clinically diagnosed with ≤cT1 disease. In the univariable analyses, computed tomography urography (CTU)–based invasion, ureter location, hydronephrosis, high-grade cytology, high-grade biopsy, sessile architecture, age, and women sex were significantly associated with pathological upstaging (P < .05). In the multivariable analyses, CTU-based invasion and hydronephrosis remained associated with pathological upstaging (P < .05). URS biopsy-based clinical and pathological gradings were concordant in 634 (54.2%) patients. Clinical undergrading occurred in 496 (42.4%) patients.ConclusionsClinical understaging/undergrading and upstaging to muscle-invasive disease occurred in a high proportion of UTUC patients undergoing RNU. Despite the inherent selection bias, these data underline the challenges of accurate UTUC staging and grading. In daily clinical practice, URS biopsy and CTU offer the most accurate preoperative information albeit with limited predictive value when used alone. These findings should be considered when utilizing preoperative, risk-adapted strategies.     

原发性骶尾部脊索瘤的CT分型及征象

目的对治疗前原发性骶尾部脊索瘤(PSC)CT图像分型,并分析其CT征象,为诊断和个性化治疗提供依据。方法回顾性分析101例PSC患者治疗前的CT图像,包括肿瘤的部位、范围、大小、密度、肿瘤与邻近结构的关系。按照肿瘤的部位由上及下分为Ⅰ~Ⅳ型,并根据肿瘤侵犯的范围从小到大分为a^d亚型。采用Kruskal-Wallis H检验比较PSC各亚型的占比,并对各亚型之间进行两两比较。采用R×C列联表精确概率检验比较分型和亚型肿瘤钙化的发生率。采用单因素方差分析及LSD-t检验对各分型和亚型肿瘤的大小和密度进行分析、比较。结果101例PSC中,Ⅰ~Ⅳ型的发生率分别为17.8%、30.7%、36.6%、14.9%,a^d亚型的占比分别为9.9%、25.7%、58.4%、5.9%。各亚型的占比差异具有统计学意义(P=0.012)。c亚型明显高于a亚型(P=0.039),d亚型明显低于a亚型(P=0.036),其余各型之间无明显差异。各分型肿瘤内钙化的差异无统计学意义(P=0.233);各亚型肿瘤内钙化的差异有统计学意义(P=0.003),a^d亚型肿瘤钙化的比率逐渐增加。Ⅰ型肿瘤的左右径及上下径明显大于Ⅱ~Ⅳ型(P<0.05)。a亚型与b亚型肿瘤之间前后径的差异无统计学意义(P=0.102),b^d亚型之间前后径的差异均有统计学意义(P<0.05);不同亚型肿瘤之间的左右径、上下径之间的差异均有统计学意义(P<0.05),a亚型径线最小,d亚型径线最大。结论101例PSC中,Ⅱ、Ⅲ型最多见,肿瘤较少累及第一骶骨;各亚型中,a型较少见,c亚型最多见,d亚型最少见。肿瘤的密度与分型无关,肿瘤内钙化与亚型有关。Ⅰ型肿瘤侵犯的范围较Ⅱ~Ⅳ型广泛,a^d亚型肿瘤的径线逐渐增大,CT分型有利于判断肿瘤的范围。PSC诊断延迟现象比较明显,但很少发生远处侵犯和转移。CT图像可对治疗前PSC分型,为诊断和个性化治疗提供依据。     

Relationship between Neurological Deterioration and Blood Pressure/Heart Rate Variability in Patients with Acute Cerebral Infarction

ObjectivesNeurological deterioration (ND) during hospitalization is an independent predictor of poor prognosis after stroke. Risk factors affecting early ND within 48 h post stroke have been intensively investigated, while few data are available on those for late ND after transfer to a wheelchair. Therefore, it was investigated whether hemodynamic factors may affect the late ND during hospitalization.Materials and methodsA retrospective study was conducted on 135 patients with atherothrombotic or cardiogenic cerebral infarction who were admitted to our hospital between April 1st, 2014 and July 31st, 2017. During hospitalization, average, maximum, and minimum values were determined for systolic blood pressure (sBP), diastolic BP (dBP), and heart rate (HR), respectively.135 patients were classified into two groups; ND (+) group, in which modified Barthel index score at the time of transfer to a wheelchair showed five points or more decrease between wheelchair transfer and discharge, and ND (?) group, which did not. Vital indices were compared between the two groups and subjected to ROC-curve analysis.ResultsThe ND (+) group included 32 patients, and the ND (?) 103. Significant differences were found between the groups in four items; sBPmin (p = 0.029), dBPmin (p = 0.019), HRave (p = 0.028), and HRmax (p < 0.01). The ND (+) group showed lower sBPmin and dBPmin, and higher HRave and HRmax than the ND (?) group.ConclusionsLate ND after transfer to a wheelchair is related to the vital indices during hospitalization and should be cautiously managed to prevent late ND