Litigants' epicondylitis

The speculated pathological causes of tennis elbow and the part work might play in its causation are briefly reviewed. The excellent surgical results, whatever operative technique was employed in those surgical series reported prior to the wave of work-related upper limb disorders is noted. One hundred and eight consecutive patients with tennis elbow who were also litigants (seeking compensation) were reviewed and the result of treatment and specifically surgery, analysed. Disappointing results of surgery were found in litigants and recommendations are made as to the management of litigants epicondylitis.     

Radiofrequency medial branch neurotomy in litigant and nonlitigant patients with cervical whiplash: a prospective study.

STUDY DESIGN: The efficacy of radiofrequency medial branch neurotomy to treat cervical zygapophysial joint pain from whiplash was compared prospectively in litigants and nonlitigants. OBJECTIVES: 1) To assess the effect of monetary gain on treatment of zygapophysial joint pain in cervical whiplash. 2) To determine whether radiofrequency medial branch neurotomy is effective treatment for whiplash. SUMMARY OF BACKGROUND DATA: The influence of litigation on treatment outcome is a subject of controversy in both the medical and legal professions. This is the first study to examine this issue in a prospective manner using a previously proven diagnostic and therapeutic method. METHODS: Sixty patients with cervical whiplash who remained symptomatic after 20 weeks of conservative management were referred for radiofrequency cervical medial neurotomy. The patients were classified as litigant or nonlitigant based on whether the potential for monetary gain via litigation existed. Each group underwent identical evaluation and treatment. Patients were observed for 1 year. Visual analogue scores and self-reported improvement were obtained before, immediately after, and 1 year after radiofrequency cervical medial neurotomy. RESULTS: Forty-six patients completed the study. The overall reduction in cervical whiplash symptoms and visual analogue pain scores were significant immediately after treatment (nonlitigants vs. litigants: 2.0 vs. 2.5, P = 0.36) and at 1 year (nonlitigants vs. litigants: 2.9 vs. 4.0, P = 0.05). One-year follow-up scores were higher than immediate post-treatment scores (nonlitigants vs. litigants: 2.5 vs. 3.6). The difference between litigants and nonlitigants in the degree of symptomatology or response to treatment did not reach significance. CONCLUSIONS: These results demonstrate that the potential for secondary gain in patients who have cervical facet arthropathy as a result of a whiplash injury does not influence response to treatment. These data contradict the common notion that litigation promotes malingering. This study also confirms the efficacy of radiofrequency medial branch neurotomy in the treatment of traumatic cervical facet arthropathy.     

Extra help required by litigants after simple fractures--a questionnaire based study

A questionnaire based interview of 100 patients under fracture clinic review was undertaken to assess the help required with the activities of daily living (ADL) in the first 2 weeks following fractures of the hand, wrist, neck of humerus, foot or ankle. The amount of help patients required was correlated with whether or not the patients were claiming compensation for their injuries. Twenty-five percent were litigating and this was shown to influence the amount of help a patient reported having received with dressing, shopping, cooking, housework, personal hygiene and travelling (p<0.0001) and feeding (p<0.0022), but not with getting in/out of bed (p=0.52). Complications of the fracture were not shown to increase litigation. On average litigants required over 3 h extra help per day compared with non-litigants (6.4 h versus 2.75 h).     

Incidence of intramedullary nail removal after femoral shaft fracture healing

INTRODUCTION: There are limited data on hardware removal after femoral fracture healing. We determined the incidence of intramedullary nail (IMN) removal after midshaft femoral fractures. We also studied demographic factors influencing IMN removal. METHODS: The senior author reviewed all adult femoral fractures with IMN placement in the trauma practice between July 1990 and November 2003. There were a total of 74 IMNs in 68 subjects with midshaft fractures. The incidence of hardware removal was the primary outcome measure. We also analyzed age, sex, body mass index (BMI), mechanism of injury, IMN dimensions, occupation, and Workers' Compensation Board (WCB) insurance and litigation involvement. RESULTS: Overall incidence of IMN removal was 20% (15 of 74 fractures). No significant difference was found with age (p=0.965), sex (p=0.086), BMI (p=0.423), occupation (p=0.341), insurance involvement (p=0.229), WCB involvement (p=0.663) or IMN dimensions (width, p=0.752; length, p=0.312). Litigants had the highest incidence of IMN removal (p=0.004). DISCUSSION: All hardware was removed for pain or irritation. These results suggest that litigants require hardware removal more often than nonlitigants. A larger study is needed to identify specific criteria for hardware removal and to determine whether secondary gains affect the incidence of femoral removal.     

Can brief measures effectively screen for pain and somatic malingering? Examination of the Modified Somatic Perception Questionnaire and Pain Disability Index

Background contextRecent rise in fraudulent disability claims in the United States has resulted in psychologists being increasingly called upon to use psychological tests to determine whether disability claims based on psychological or somatic/pain complaints are legitimate.PurposeTo examine two brief measures, Modified Somatic Perception Questionnaire (MSPQ) and the Pain Disability Index (PDI), and their ability to screen for malingering in relation to the Bianchini et al. criteria for malingered pain-related disability published in The Spine Journal (2005).Study designExamined brief self-report measures between litigating and nonlitigating pain samples.Patient sampleWe compared 144 disability litigants, predominantly presenting a history of musculoskeletal injuries with psychiatric overlay, with 167 nonlitigating pain patients who were predominantly in treatment for chronic back pain issues and other musculoskeletal conditions.Outcome measuresModified Somatic Perception Questionnaire, Pain Disability Index, Minnesota Multiphasic Personality Inventory-2 Restructured Form, Test of Memory Malingering, Letter Memory Test, Victoria Symptom Validity Test, Structured Interview of Reported Symptoms-second edition, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders somatoform disorders module.MethodsWe examined a sample of 144 individuals undergoing compensation-seeking evaluations in relation to 167 nonlitigating pain patients.ResultsGroup differences on both the MSPQ and PDI were calculated, as well as sensitivities, specificities, and positive and negative predictive powers for both measures at selected cutoffs.ConclusionsThe results suggest that both the MSPQ and PDI are useful to screen for pain malingering in forensic evaluations, especially the MSPQ, which performed the best in differentiating between the groups.     

Response bias in plaintiffs histories

This study investigated response bias in self reported history of factors relevant to the assessment of traumatic brain injury, toxic brain injury and related emotional distress. Response bias refers to systematic error in self report data. A total of 446 subjects comprising 131 litigating and 315 non litigating adults from five locations in the United States completed a symptom questionnaire. Data were obtained from university faculty and students, from patients in clinics specializing in physiatry, neurology, and family medicine, and from plaintiffs undergoing forensic neuropsychological evalua tions. Comparisons were made for litigant and non litigant ratings of their past and current cognitive and emotional functioning, including life in general, ability to concentrate, memory, depression, anxiety, alcohol, drugs, ability to work or attend school, irritability, headaches, confusion, self esteem, and fatigue. Although there is no basis for hypothesizing plaintiffs to be healthier than the general population, plaintiffs rated their pre injury functioning superior to non plaintiffs. These findings suggest that response biases need to be taken into account by forensic examiners when relying on litigants self reports of pre injury status.     

Deux cas d’encéphalite autoimmune à anticorps antirécepteur N-méthyl-D-aspartate en réanimation

We report here two cases of autoimmune encephalitis associated with antibodies against the N-methyl-D-aspartate receptor. The primary cause was an ovarian teratoma in one case. The outcomes were good. The first case was a late diagnosis, despite a typical clinical presentation. The clinical presentation of this disease remains unknown, especially in the intensive care unit. The treatment was recently codified and transformed the prognosis of this encephalitis. The second case was early treated in the course of the disease, due to the experience related to the previous case. In case of unexplained acute or subacute encephalitis or psychiatric-like disorders without prior medical history, the determination of the level of expression of antibodies against the N-methyl-D-aspartate receptors and other antineuroreceptors antibodies can help to identify this diagnosis. The initial picture of the disease, its variability and the unawareness of the recent reports on this encephalitis may lead to a wrong diagnosis and inappropriate management.     

多层螺旋CT足踝部隐匿性骨折的诊断价值

目的：通过对隐匿性骨折的诊断,提示足踝部外伤后X线检查阴性、临床高度怀疑有骨折的患者进行多层螺旋CT检查的必要性,以期减少漏诊、误诊。方法：收集2007年1月至2010年6月31例足踝部外伤病例,男18例,女13例;年龄21～67岁,平均35岁。均有明确外伤史,主要表现为足踝部疼痛,局部肿胀,压痛点固定,压痛明显,活动受限。31例X线检查均阴性,因临床高度怀疑骨折而行多层螺旋CT检查。结果：螺旋CT检查发现11例骨折,共累及17处。单发骨折6例,多发骨折5例。单发骨折中,外踝骨折1例,距骨骨折1例,足舟骨骨折1例,第5跖骨基底部骨折1例,跟骨骨折2例;多发骨折中,内、外踝骨折1例,内踝、跟骨、距骨骨折1例,距骨、足舟骨骨折1例,足第1、2楔骨骨折1例,第2、3跖骨基底部骨折1例。结论：足踝部外伤后X线片检查阴性、临床高度怀疑有骨折的患者进行多层螺旋CT检查,可明显提高隐匿性骨折的检出率,为临床治疗及司法鉴定提供可靠的影像学依据,具有重要的应用价值。     

Ambulatory laparoscopic cholecystectomy: An audit of day case vs overnight surgery at a community hospital in Japan

AIM: To evaluate the applicability and safety of ambulatory laparoscopic cholecystectomy (LC) and to compare day case and overnight stay LC.METHODS: Data were collected retrospectively and consecutively for day case and overnight stay LC patients from July 1, 2009 to April 30, 2011. Outcomes were analyzed for patient demographics, operation time, blood loss during operation and frequency and reasons for unexpected or prolonged hospitalization in each group.RESULTS: There was no hospital mortality and no patient was readmitted with serious morbidity after discharge. 50 patients received a day case LC and 19 had an overnight stay LC. There was a significant difference in age between both groups (P < 0.02). There were no significant differences between the day case LC performed (n = 41) and failed (n = 9) groups and between the day case LC performed and the one night stay LC (n = 12) groups. There was a significant difference in age between the one night stay and more nights stay LC groups (P < 0.05). Thus, elderly patients showed a tendency to like to stay in hospital rather than being a day case. The proportion of unexpected or prolonged hospitalization was not significantly different between the day case and overnight stay LC groups, when the patient’s request was excluded.CONCLUSION: Day case LC can be performed with a low rate of complications. In overnight stay patients, there are many who could be performed safely as a day case. Moreover, we need to take special care to treat elderly patients.     

Hémorragie digestive par rupture d'un anévrisme des artères viscérales. Présentation de quatre observations

Study aimGastrointestinal bleeding by rupture of splanchnic artery aneurysms is very rare. The aim of this study is to report four cases observed between 1990 and 1996.Materials and methodsIn the first case, the celiac trunk aneurysm was revealed by hematemesis due to erosion of the posterior wall of the stomach. Excision of the aneurysm associated with splenopancreatectomy was followed by revascularization of the common hepatic artery with a bypass implanted in the aorta. The second case concerned a splenic artery aneurysm revealed by hemosuccus pancreaticus and intestinal bleeding which was treated by excision and splenopancreatectomy. In the third case, the common hepatic artery aneurysm revealed by hemosuccus pancreaticus and intestinal bleeding was treated by obstructive endoaneurysmorrhaphy. The fourth case concerned a superior mesenteric aneurysm revealed by duodenal erosion causing gastric and intestinal bleeding, which was treated by obstructive endoaneurysmorrhaphy and revascularization of the mesenteric artery by a spleno-mesenteric bypass.ResultsSurgical treatment was successful in all four patients. In the first case, an acute acalculous cholecystitis required a cholecystectomy after 3 weeks. In the fourth case, a splenic infarction disappeared spontaneously.ConclusionSuch observations are rare. The site of the bleeding was located by endoscopy. The aneurysm was recognized by contrast-enhanced computerized tomography (CT) scan and/or celiac and mesenteric arteriography which was performed in all cases and was very useful for the management of such aneurysms. After excision (n = 2) or obliterative endoaneurysmorrhaphy (n = 2), revascularization had to be done in two cases for celiac and mesenteric aneurysms.     

Case report of an abscess developing at the site of a hematoma following a direct lateral interbody fusion

Background contextA direct lateral interbody fusion (DLIF) is relatively new, yet commonly performed procedure in spine surgery. This procedure is associated with risk, including damage to nerve or vascular structures. However, to our knowledge, there has not been a case of an abscess developing at the site of a postoperative hematoma after this procedure.PurposeThe objective was to document a case of the delayed presentation of an abscess at the site of a postoperative hematoma after a DLIF.Study design/settingThe study was designed to be a case report and literature review.MethodsWe present a case of a 63-year-old patient who developed a large retroperitoneal hematoma after an L2–L5 DLIF. The patient developed a postoperative urinary tract infection with cultures positive for Pseudomonas. The infection was treated with oral antibiotics. Eight months after her procedure, the patient was found to have developed an abscess (measuring 11.6 × 8.4 × 10.0 cm) at the site of the prior hematoma.ResultsAfter radiological-guided aspiration and a 2-week course of oral antibiotics, the abscess resolved and the patient recovered with no sequelae.ConclusionDirect lateral interbody fusion is a minimally invasive procedure that may result in postoperative hematoma formation. We have reported a case of the development of an abscess at the site of a postoperative hematoma.     

Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis: Outcome 10 years following open reduction and K-wire fixation

IntroductionSalter-Harris type IV fracture of the proximal phalanx with 90° rotation of the epiphysis is very rare. We report on a case of Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis and document the outcome 10 years after surgery.Presentation of caseA 5-year old boy presented with Salter-Harris type IV fracture of the thumb with 90° rotation of the epiphysis. Open reduction and K-wire fixation was done. Ten years later, the injured thumb was smaller in width when compared to the contralateral thumb, although there was no length discrepancy. Clinically, there was full range of motion. Radiologically, the physis was still open but there were minor irregularities at the adjacent metaphyseal base and epiphysis. The diaphysis of the injured proximal phalanx had a constricted appearance when compared to the contralateral normal side.DiscussionAfter an extensive literature review, we found one reported case which was similar to our case and had long term assessment. At skeletal maturity, there was complete remodeling and full range of motion of the digit with no shortening. The X-ray showed a constricted diaphysis of the proximal phalanx with an identical appearance to our case.ConclusionWe present a rare case of Salter-Harris type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis. Long term outcome was satisfactory but there was diaphyseal constriction leading to a narrower thumb.     

Collapsing Focal Segmental Glomerulosclerosis After Kidney Transplantation: Is It a Consequence of Viral Infections?

BackgroundThe aim of this case study was to explore the possible link between viral infections and collapsing focal segmental glomerulosclerosis (cFSGS) in patients who underwent kidney transplantation.MethodsThis case study included 3 case reports of patients who underwent kidney transplantation. The case reports were presented clinically and pathohistologically with cFsGS as a possible consequence of viral infections.ResultsThe first patient developed cFSGS after polymerase chain reaction for SARS-CoV2 was positive twice. He gradually developed terminal stage chronic kidney disease. The second patient developed cFSGS with high range proteinuria after cytomegalovirus infection, which has been treated with 3 lines of antiviral medicaments. The third patient developed cFSGS as a possible consequence of hepatitis B virus infection.ConclusionsThis case study highlighted the importance of viral etiology in the pathway of cFSGS. Pathogenic links between viral infections and concomitant glomerulopathies are challenging, especially in immunocompromised transplanted patients.     

Paraduodenal pancreatitis as an uncommon cause of gastric outlet obstruction: A case report and review of the literature

IntroductionParaduodenal pancreatitis (PP) is an under-recognized form of focal chronic or recurrent pancreatitis. Since PP presents with non-specific symptoms and shares radiological and histopathological features with other entities, it can be challenging to diagnose.Presentation of case reportHerein, a case of a 64 year-old Caucasian male with PP presenting with recurrent gastric outlet obstruction (GOO) is detailed. Over the course of two years, he underwent multiple balloon dilatations for symptom management. His diagnostic course was complicated by inconclusive and misleading biopsies.ConclusionPP can rarely present as GOO in otherwise asymptomatic patients. A preoperative pathologic diagnosis can be difficult to obtain, and in this case delayed definitive surgical management. The case is discussed in detail, and a concise review the current literature was undertaken.     

Silverhawk斑块切除成形治疗严重膝下动脉硬化闭塞性病变

目的：探讨Silverhawk斑块切除成型治疗严重膝下动脉硬化闭塞性病变的安全性和有效性。 方法：回顾分析2年来治疗的9例该病患者临床与随访资料。其中男性3例,女性6例,平均年龄（64.0±9.1）岁,病程（28.9±25.9）个月;下肢间歇性跛行5例,静息痛1例,足趾溃疡1例,坏疽2例;6例病变位于胫腓干动脉,1例位于胫前动脉,2例位于胫后动脉;1例行单纯斑块切除,余8例患者均同时采用介入技术处理了流入道动脉病变。 结果：所有手术均获得成功。出院时所有患者再通血管保持通畅。跛行患者跛行距离均增至500 m以上,1例静息痛术后缓解,1例足趾溃疡面积缩小,2例坏疽呈干性无感染。患者术后踝肱比值（ABI）均较术前增加。所有患者得到随访,平均时间为（24.0±9.5）个月。1例患者术后23个月因心肌梗死死亡;1例患者间歇性跛行距离较术后最好时期有所减少,但仍优于术前;静息痛患者疼痛症状消失;溃疡患者伤口愈合;2例坏疽患者,1例仍保持干性状态,另1例其坏疽两趾脱落,创面愈合。 结论：Silverhawk斑块切除成型治疗严重膝下动脉硬化闭塞病变是一种安全有效的方法,是否能够成为一种常规的技术,还需要随机对照研究远期结果的验证。

     

Triorchidism: two case reports

In this study, two cases of triorchidism are reported. The first case (29 years) had two right discrete ovoid nontender, firm, mobile lumps with testicular sensation. The second case (32 years) had two left discrete ovoid nontender, firm, mobile lumps with normal testicular sensation. They were subjected to the estimation of serum follicle‐stimulating hormone, luteinising hormone, free and total testosterone, alpha‐fetoprotein, prostate‐specific antigen, karyotyping and semen analysis. Imaging included ultrasonography, transrectal ultrasound, magnetic resonance imaging and intravenous pyelography. The first case had two testes in the right side. Each one had an epididymis where one vas deferens was palpated. The second case had two left testes with normal testicular sensation. The lower left lump represented normal‐sized testis attached to its epididymis and a single palpated vas deferens. Diagnosis of the first case was triorchidism associated with left varicocele (grade I) with oligoasthenoteratozoospermic semen profile. Intracytoplasmic sperm injection was carried out resulting in a twin. Diagnosis of the second case was triorchidism with accessory testis on the left side associated with left varicocele (grade I) and asthenozoospermic semen profile that was submitted to medical treatment. It is concluded that triorchidism is an uncommon congenital anomaly that should be not overlooked in diagnosing scrotal masses.     

Dislocation of the Carpometacarpal Joint of the Thumb Associated with Trapezium and Bennett’s Fractures

We report a case of a 30-year-old man with a carpometacarpal joint dislocation of the thumb associated with trapezium and Bennett’s fractures. This combined injury pattern appears to be very rare. Since, to our knowledge a similar case was not found in the literature. The lesion was managed with closed reduction and percutaneous pining, resulting in good functional outcome.     

Paradoxical response of blood pressure to salt loading in renovascular hypertension

We studied the effect of high salt intake on blood pressure in two cases with renovascular hypertension. They had hypertension with hyperreninemia and marked difference in plasma renin activity between both renal veins. Blood pressure significantly decreased after single oral administration of captopril. Renal arteriogram revealed significant stenosis in the main artery to the left (case 1) and right (case 2) kidney. Blood pressure response was evaluated after seven (case 1) and five (case 2) days of low salt and seven days (both cases) of high salt intake. Mean blood pressure in two patients was significantly decreased (case 1; 118 +/- 5.5 to 108 +/- 6.1 mmHg and case 2; 150 +/- 3.8 to 138 +/- 3.1 mmHg). Plasma renin activity was also decreased (case 1; 6.25 to 0.77 ng/ml/hr and case 2; 22.8 to 6.3 ng/ml/hr). In case 2, blood pressure elevated markedly during low salt intake, compared with blood pressure level during normal salt intake. The results suggest that excessive salt intake in patients with unilateral renovascular hypertension produces blood pressure reduction because of suppression of renin-angiotensin system. We concluded that in patients with unilateral renovascular hypertension dietary sodium depletion may be harmful, whereas salt supplement may have a beneficial effect.     

Male pseudohermaphroditism by persistent müllerian structures

We have studied 2 cases of nonfamilial male pseudohermaphroditism by persistent müllerian ducts. The first case, found in a fourteen-year-old male, can be described as the classic form of cryptorchism which resisted hormonal treatment and in which a rudimentary uterus with fallopian tubes and atrophic testicles were found at exploratory laparotomy. The second case was discovered in a thirty-nine-year-old man who had bilateral cryptorchism. He presented with an abdominal mass which was found to be a seminoma in the right intra-abdominal testicle, and a well-defined uterus with fallopian tubes and an atrophic left testicle were seen. Neither case presented phenotype disturbances. Both karyotypes were 46 XY. A total resection of the female sexual organs and testicles was performed in both patients, and the mass was removed in the second case. The tumoral degeneration of the intra-abdominal testicles in this syndrome is found in similar proportion to the simple cryptorchid testicles. Our second case is the tenth one of a testicular tumor in pseudohermaphroditism by persistent müllerian ducts to be reported in the literature.     

Finite element investigation of the effect of a bifid arch on loading of the vertebral isthmus

BackgroundThe biomechanical effect of a bifid arch as seen in spina bifida occulta and following a midline laminectomy is poorly understood.PurposeTo test the hypothesis that fatigue failure limits will be exceeded in the case of a bifid arch, but not in the intact case, when the segment is subjected to complex loading corresponding to normal sporting activities.Study designFinite element analysis.MethodsFinite element model of an intact L4-S1 human lumbar motion segment including ligaments was used. A section of the L5 vertebral arch and spinous process was removed to create the model with a midline defect. The models were loaded axially to 1 kN and then combined with axial rotation of 3°. Bilateral stresses, alternating stresses, and shear fatigue failure on both models were assessed and compared.ResultsUnder 1 kN axial load, the von Mises stresses observed in midline defect case and in the intact case were very similar (differences <5 MPa) having a maximum at the ventral end of the isthmus that decreases monotonically to the dorsal end. However, under 1 kN axial load and rotation, the maximum von Mises stresses observed in the ipsilateral L5 isthmus in the midline defect case (31 MPa) was much higher than the intact case (24.2 MPa), indicating a lack of load sharing across the vertebral arch in the midline defect case. When assessing the equivalent alternating shear stress amplitude, this was found to be 22.6 MPa for the midline defect case and 13.6 MPa for the intact case. From this, it is estimated that shear fatigue failure will occur in less than 70,000 cycles, under repetitive axial load and rotation conditions in the midline defect case, whereas for the intact case, fatigue failure will occur only after more than 10 million cycles.ConclusionsA bifid arch predisposes the isthmus to early fatigue fracture by generating increased stresses across the inferior isthmus of the inferior articular process, specifically in combined axial rotation and anteroposterior shear.