The ‘antiphospholipid syndrome’ and the ‘lupus anticoagulant’

In recent years an association has been described between, on the one hand, an in vitro prolongation of phospholipid-dependent coagulation tests (the lupus anticoagulant) or the demonstration of antiphospholipid antibodies and, on the other, clinical events, particularly recurrent thrombosis (usually venous but sometimes arterial), thrombocytopenia, and also recurrent mid-term fetal loss. Other less well-documented associations with haemolytic anaemia, livedo reticularis, strokes and other neurological syndromes have been suggested. The antibodies are present temporarily in many infections, are usually of IgM isotype and thrombosis does not occur. However, they are persistently present and mainly of IgG isotype in a number of auto-immune disorders associated with thrombosis, in particular systemic lupus erythematosus, in which 50% of patients will show antibody of one isotype or another. The strongest association is with antinuclear factor-negative lupus and lupus-like disorders in which a full diagnosis of classical lupus cannot be made. The clotting test abnormality and antiphospholipid antibodies may be found also in otherwise normal individuals suffering thrombosis or fetal loss — the so-called primary antiphospholipid syndrome. These data raise important questions for management, but many details are controversial despite a decade's work; this review examines the present position and outlines some of the difficulties, particularly from the point of view of nephrology and paediatrics.     

The ‘clitoromotor’ reflex

The effect of glans clitoris (GC) stimulation on the vagina, uterus and pelvic floor muscles (levator ani (LA) or pubococcygeus, puborectalis (PR)) was studied in 16 healthy volunteers (mean age 34.9 years). The GC was stimulated mechanically and electrically while recording the vaginal and uterine pressures and the electromyographic activity of PR and LA. Stimulation caused a drop in the uterine (P<0.001) and upper vaginal (P<0.05) pressures (1.6 and 2.9 cmH₂O, respectively) and an increase in the middle (P<0.001) and lower (P<0.001) vaginal pressures (58.6 and 89.2 cmH₂O, respectively). It also effected an increase of EMG activity in the PR (P<0.01) and LA (P<0.01). Response was greater with electrical than with mechanical stimulation (P<0.05). No response occurred upon stimulation of the anesthetized GC or the anesthetized PR or LA. The reproducibility of the PR and LA contraction on GC stimulation postulates a reflex relationship which we call the clitoromotor reflex. This induces uterovaginal changes that enhance the sexual response of both partners, and also prepares the uterus and vagina for the reproductive process. LA contraction pulls open and reduces the pressure in the upper vagina as well as elevating the cervix uteri. PR contraction constricts the middle and lower vagina and increases their pressure.Editorial Comment: This article describes a reflex which is operative during coitus. It results in ballooning of the upper vagina (assuming lateral sidewall attachments are intact) and contraction of the paravaginal muscles. The study is nicely done and objectively establishes the existence of this physiological reflex.     

Biomechanical considerations in ‘biological’ femoral osteosynthesis: an experimental study of the ‘bridging’ and ‘wave’ plating techniques

Although traditional compression plate fixation aims to abolish interfragmentary movement and achieve primary bone healing, the more recent ‘biological’ plate fixation methods such as the ‘bridging’ and ‘wave’ plate techniques aim to maintain fracture alignment without absolute stability and promote union by callus formation. Furthermore, some mechanical advantages have been attributed to the ‘wave’ plate fixation. Since no data have been published on the mechanical characteristics of the ‘bridging’ and ‘wave’ plate fixation methods, the aim of this biomechanical comparative study was to investigate the rigidity of those fixation methods in various types of femoral diaphyseal fractures. Using a composite femoral model, the rigidity characteristics of three fixation methods (short DCP, ‘bridging’ and ‘wave’ plates) were investigated. The results showed that when cortical contact between the main fragments is present, a ‘bridging’ plate can be equally rigid to the ‘wave’ plate in mediolateral bending by displaying a similar tension-band effect. Furthermore, in the absence of cortical contact, the axial fixation rigidity of the long ‘bridging’ plate is superior to that of the ‘wave’ plate. Both methods showed a significant ‘stress-shielding’ effect on the intact femur. In conclusion, this in vitro study failed to show any significant mechanical advantages of the ‘wave’ plate technique over the ‘bridging’ plating method. It appears that the ‘bridging’ plate fixation may be the mechanically optimal ‘biological’ plating method for the femoral diaphysis. Received: 26 May 1999     

Trabucco’s ‘suture-less tension-free’ hernia repair: technique,local anesthesia and results

Hernia repair has always been performed by approximation of the inguino-crural structures. Since these structures are not normally in apposition, their approximation may be associated with undue tension on the suture line: this can cause recurrences. ‘Tension-free’ techniques solved this problem, and permit a remarkable reduction in recurrence rate.     

‘Making Concave Faces Convex’

Inadequate projection of the midface skeleton results in midface concavity. Patients with this skeletal morphology tend to have prominent eyes and noses. Lack of skeletal support for the midface soft tissue envelope predisposes to premature cheek descent, resulting in palpebral fissure distortion and lower lid “bags,” an appearance of early aging. Concave midfaces can be made convex with two basic maneuvers performed through intraoral and periorbital incisions. Midface skeletal projection can be increased by augmenting the facial skeleton with alloplastic implants. Multiple implants are required to replicate the complex curvature of the midface skeleton and to avoid impingement on the infraorbital nerve. Subperiosteal elevation of the midface soft tissues and repositioning provides cheek fullness and narrows the palpebral fissure while masking eyelid “bags.” The resultant midface concavity makes the eyes and nose appear less prominent. This procedure has been a safe and effective treatment for 14 patients treated over a 4-year period.Presented at the 17th Congress of the International Society of Aesthetic Plastic Surgery in Houston Texas, October, 2004     

Definitional Differences of ‘Outpatient’ Versus ‘Inpatient’ THA and TKA Can Affect Study Outcomes

Background

There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated “outpatient” status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients who are “observed” for one or more nights. Current regulations in the United States allow these “observed” patients to stay more than one night at the hospital under observation status despite being coded as outpatients. Determining the degree to which this is the case, and what, exactly, “outpatient” means in the NSQIP, may influence the way clinicians read studies from that source and the way hospital systems and policymakers use those data.

Questions/Purposes

The purposes of this study were (1) to utilize the NSQIP database to characterize the differences in definition of “inpatient” and “outpatient” (stated status versus actual length of stay [LOS], measured in days) for THA and TKA; and (2) to study the effect of defining populations using different definitions.

Methods

Patients who underwent THA and TKA in the 2005 to 2014 NSQIP database were identified. Outpatient procedures were defined as either hospital LOS = 0 days in NSQIP or being termed “outpatient” by the hospital. The actual hospital LOS of “outpatients” was characterized. “Outpatients” were considered to have stayed overnight if they had a LOS of 1 day or longer. The effects of the different definitions on 30-day outcomes were evaluated using multivariate analysis while controlling for potential confounding factors.

Results

Of 72,651 patients undergoing THA, 529 were identified as “outpatients” but only 63 of these (12%) had a LOS = 0. Of 117,454 patients undergoing TKA, 890 were identified as “outpatients” but only 95 of these (11%) had a LOS = 0. After controlling for potential confounding factors such as gender, body mass index, functional status before surgery, comorbidities, and smoking status, we found “inpatient” THA to be associated with increased risk of any adverse event (relative risk, 2.643, p = 0.002), serious adverse event (relative risk, 2.455, p = 0.011), and readmission (relative risk, 2.775, p = 0.010) compared with “outpatient” THA. However, for the same procedure and controlling for the same factors, patients who had LOS > 0 were not associated with any increased risk compared with patients who had LOS = 0. A similar trend was also found in the TKA cohort.

Conclusions

Future THA, TKA, or other investigations on this topic should consistently quantify the term “outpatient” because different definitions, stated status or actual LOS, may lead to different assignments of risk factors for postoperative complications. Accurate data regarding risk factors for complications after total joint arthroplasty are crucial for efforts to reduce length of hospital stay and minimize complications.

Level of Evidence

Level III, therapeutic study.

     

Tibial hemimelia with ‘mirror foot’

Mirror foot anomalies are extremely rare forms of duplications of toes. They can be associated with several other anomalies such as mirror hands, fibular dimelia, tibial hypoplasia/aplasia or facial deformities. A case of a mirror foot anomaly in association with an extremely rare variant of tibial hemimelia is presented. Other similar cases in the literature and modern theories regarding the aetiology are also presented.     

The role of diagnostic block in the management of Morton’s neuroma

Objective

To determine the outcome of surgical excision of Morton’s neuroma after a local anesthetic diagnostic block into the neuroma has relieved symptoms.

Design

A cohort study.

Setting

A university affiliated hospital.

Patients

A sequential series of 37 patients who underwent 41 excisions with at least 2 years’ follow-up. Seven patients had undergone repeat excision of a neuroma, and 34 primary excisions were performed. Surgery was performed by a specialist in orthopedic surgery of the foot and ankle.

Intervention

Excision of the Morton’s neuroma after a positive diagnostic block.

Main outcome measures

Grade of symptoms at follow-up done by independent review on a 4-point scale.

Results

Of 41 procedures, 11 had an unfavourable outcome: 4 procedures were graded 3, and 7 procedures were graded 4. Eight (24%) of the 34 primary procedures were reported as failures, and 3 (43%) of the 7 revision procedures were reported as failures. Most patients reported poor results owing to persistent pain.

Conclusions

Diagnostic blocks do not improve the results of surgery for excision of Morton’s neuroma and are not recommended. Because failure rates are greater than 20%, surgery for Morton’s neuroma should only be offered after a full course of nonoperative management.     

Discrimination of ‘Driver’ and ‘Passenger’ HPV in Tonsillar Carcinomas by the Polymerase Chain Reaction, Chromogenic In Situ Hybridization, and p16INK4a Immunohistochemistry

Human papillomavirus (HPV) positive tonsillar squamous cell carcinoma (TSCC) is associated with a favorable clinical outcome. However, the HPV detected in a given tumor may be causal (driver HPV) or an incidental bystander (passenger HPV). There is a need to discriminate these forms of HPV in TSCCs to understand their impact on HPV as a biomarker for use in TSCC patient management. This study has compared the polymerase chain reaction (PCR), chromogenic in situ hybridization (CISH), and p16^INK4a immunohistochemistry in the assessment of HPV status in TSCC. Archival specimens of TSCC from thirty patients were investigated. HPV was detected by PCR in 25/30 (83.3%) tumors; HPV16 (70.0%) and HPV52 (6.7%) were the most common types. HPV was corroborated by CISH in 22/25 (88.0%) specimens; integrated HPV was implicated by the presence of punctate signals in each of these cases. p16^INK4a staining was found in 20/22 (90.9%) HPV PCR positive samples; two PCR/CISH HPV positive cases were p16^INK4a negative and two HPV negative samples were p16^INK4a positive. These data suggest that a minority of HPV positive TSCCs are positive for passenger HPV and that two or more assays may be required for diagnosing driver HPV status. Further studies are required to exam whether oropharyngeal tumors positive for passenger HPV have a less favorable prognosis than tumors that are driver HPV positive. The clinical significance of TSCCs that test HPV negative/p16^INK4a positive, PCR and CISH HPV positive/p16 ^INK4a negative, or PCR HPV positive/p16 ^INK4a and CISH negative, also requires further investigation.