Chronic pain due to Little Leaguer’s Shoulder in an adolescent baseball pitcher: a case report

Objective:

To describe a case of chronic Little Leaguer’s Shoulder in reference to pain presentation, physical capabilities, and recovery time.

Clinical Features:

A 17-year-old, junior baseball pitcher presented with shoulder pain when performing high velocity pitching. Conservative treatment for an assumed soft tissue injury failed to resolve the pain, which was regularly aggravated by pitching, and which subsequently prompted further evaluation, and eventual confirmation of Little Leaguer’s Shoulder on subsequent computerized tomography (CT) imaging.

Intervention and Outcome:

Prior to proper diagnosis, conservative treatment had consisted of activity modification, spinal adjusting, laser therapy, shockwave therapy, Active Release Techniques^®, Kinesiotape,^® and rehabilitation. Later, rehabilitation, consisting of general muscle and core strengthening, continued for a further six months under the supervision of college athletic trainers. The athlete was able to return to normal pitching duties approximately 12 months later.

Summary:

In this case, a potentially damaging bone injury masquerading as a simple musculo-tendinous injury created a diagnostic challenge. The patient eventually recovered with rest, time, strengthening, and eventual compliance to prescribed activity modification.     

Medial ulnar collateral ligament reconstruction of the elbow in major league baseball players: Where do we stand?

The ulnar collateral ligament(UCL) is a vital structure to the overhead athlete,especially the baseball pitcher.For reasons not completely understood,UCL injurieshave become increasingly more common in major league baseball(MLB) pitchers over the past 10 years.UCL reconstruction(UCLR) is the current gold standard of treatment for these injuries in MLB pitchers who wish to return to sport(RTS) at a high level and who have failed a course of non-operative treatment.Results following UCLR in MLB pitchers have been encouraging,with multiple RTS rates now cited at greater than 80%.Unfortunately,with the rising number of UCLR,there has also been a spike in the number of revision UCLR in MLB pitchers.Similar to primary UCLR,the etiology of the increase in revision UCLR,aside from an increase in the number of pitchers who have undergone a primary UCLR,remains elusive.The current literature has attempted to address several questions including those surrounding surgical technique(method of exposure,graft choice,management of the ulnar nerve,concomitant elbow arthroscopy,etc.),post-operative rehabilitation strategies,and timing of RTS following UCLR.While some questions have been answered,many remain unknown.The literature surrounding UCLR in MLB pitchers will be reviewed,and future directions regarding this injury in these high level athletes will be discussed.     

The lived experience and quality of life with burn scarring—The results from a large-scale online survey

A large-scale online survey was designed to both inform and direct the development of an online community healthcare hub for people living with scarring. Focussed areas of questioning were generated to gather information on psychological symptoms, scar support and knowledge of wounds and healing. Simple statistical data was produced on the severity, aetiology and location of scarring. A secondary data analysis of the survey responses was conducted on more focussed themes. This survey was completed by 1034 people living with scars, 119 of which had burn scarring. The results highlight that patients with burn scars have higher levels of pre-existing psychological difficulties, carry a greater number of scars and experience more symptoms. A lack of support is identified for patients with scars once they have been discharged by their healthcare provider. The most popular forms of support were chosen as face-to-face interaction or online support. Key areas of support were found to be psychology particularly for help with acceptance or coping methods, wound care advice and meeting with other patients with scars. For these patients, key themes in the psychological impact of scarring include appearance-related concerns, social anxiety, acceptance and coping, experience of symptoms, skin viability and survivorship.     

Patients’ information and perspectives on biosimilars in rheumatology: A French nation-wide survey

ObjectiveTo assess the patients' information about biosimilars and to identify the patients’ incentives and deterrents to concur with the use of biosimilars.MethodsNation-wide cross-sectional study assessing information and concerns about biosimilars of French patients treated for rheumatic inflammatory diseases, whether they were treated or not by a biological DMARD. The assessment was available online from March to July 2017.ResultsAmong the 629 respondents, 43% knew what biosimilars were. The main sources of information were rheumatologists and patient associations. Among patients treated with a biosimilar, 44% were not informed before they received the treatment. The patients’ concerns focused on the non-similar molecular structure (46%), efficacy (60%) and safety (57%) comparatively to the originator biologic. 15% of respondents would refuse to switch their biologic to its biosimilar. More than 50% of respondents would warily accept to switch medications and interrupt the treatment if in doubt. Being informed about biosimilars and a good understanding of the definition of biosimilars were characteristics associated with better adherence to biosimilars. The rheumatologist was considered the most influent source of information about biosimilars and was considered reliable when deciding to switch a biologic to its biosimilar. Patient were reluctant to substitution of the medications by pharmacists (2%). Medico-economical issues acted as an incentive and a deterrent to accept the switch of medication.ConclusionBiosimilars are largely unknown to patients. Information seems to be instrumental in improving the patients’ adherence to biosimilars and could help preserving the therapeutic relationship and avoiding a nocebo effect.     

The complication trends of pediatric spinal deformity surgery in Japan – The Japanese Scoliosis Society Morbidity and Mortality survey from 2012 to 2017

BackgroundThe Japanese Scoliosis Society Morbidity & Mortality Committee performed a longitudinal nationwide complication survey of spinal deformity surgery from 2012 to 2017. The present study aimed to analyze the survey results and report the complication trends of pediatric spinal deformity surgery in Japan.MethodsAll Japanese Scoliosis Society members were invited to participate in the survey. Diagnoses were grouped into idiopathic scoliosis, congenital scoliosis, neuromuscular scoliosis, other types of scoliosis, and pediatric kyphosis. Complications were grouped into death, blindness, neurological deficits (motor/sensory), infection, massive bleeding, hematoma, pneumonia, cardiac failure, deep vein thrombosis/pulmonary embolism, gastrointestinal perforation, and instrumentation failure.ResultsThe surveys were performed in 2012, 2014, and 2017. The overall complication rate decreased from 10.7% in 2012 to 8.1% in 2017. In particular, the complication rate in patients with idiopathic scoliosis decreased from 8.8% in 2012 to 4.0% in 2017. The complication rate of patients with neuromuscular scoliosis and kyphosis remained high. The rate of neurological deficits, especially in motor deficits, significantly decreased from 2.0% in 2012 to 0.7% in 2017, and tended to be highest in patients with kyphosis. The rate of massive bleeding was significantly decreased from 3.3% in 2012 to 0.8% in 2017, especially in patients with neuromuscular scoliosis (12.2–4.4%). However, patients with neuromuscular scoliosis had a high rate of postoperative pneumonia (3.7%, 2.6%, and 5.1%, respectively). The rate of instrumentation failure was also high (2.1%, 1.5%, and 2.2%, respectively), especially in patients with early onset idiopathic, congenital and other types of scoliosis.ConclusionsThe overall surgical complication rates in pediatric patients decreased due to decreased rates of neurological deficits and massive bleeding, especially in patients with idiopathic scoliosis. However, the complication rates remain high in patients with neuromuscular scoliosis and kyphosis.     

The complication trends of adult spinal deformity surgery in Japan – The Japanese Scoliosis Society Morbidity and Mortality survey from 2012 to 2017

BackgroundThe Japanese Scoliosis Society Morbidity & Mortality Committee performed a longitudinal nationwide complication survey of spinal deformity surgery from 2012 to 2017. The present study aimed to analyze the survey results and report the complication trends of adult spinal deformity surgery in Japan.MethodsAll Japanese Scoliosis Society members were invited to participate in the survey. Adult spinal deformity was categorized into three groups by age: 20–39 years, 40–64 years and ≥65 years. Complications were grouped into death, blindness, neurological deficits (motor/sensory), infection, massive bleeding, hematoma, pneumonia, cardiac failure, deep vein thrombosis/pulmonary embolism, gastrointestinal perforation, and instrumentation failure.ResultsThe surveys were performed in 2012, 2014, and 2017. The overall complication rates were 21.6%, 26.0%, and 25.4%, respectively. The complication rates differed significantly by age group in all years such that older patients had a higher complication rate than younger patients. The rate of neurological deficits, particularly motor deficits, significantly increased in 2014 (3.1%–5.5%), and decreased in 2017 (4.3%). Massive bleeding and postoperative hematoma decreased significantly year by year (8.0%, 4.8%, 2.5% and 1.3%, 0.5%, 0.3%, respectively). The complication rate of instrumentation failure remained high, increasing without significant difference (5.2%, 5.8%, 6.5%, respectively), and was more common in the middle-aged and older patients.ConclusionsSurgical complication rates in patients with adult spinal deformity remain high, especially neurological deficits and instrumentation failure in patients aged over 40 years. However, the complication rates of massive bleeding and postoperative hematoma decreased over this period.     

Internal anal sphincter achalasia: data from a nationwide survey of allied disorders of Hirschsprung’s disease in Japan

Purpose

To investigate the incidence and treatment of internal anal sphincter achalasia (IASA) in Japan based on an analysis of data from a nationwide retrospective cohort study of the allied disorders of Hirschsprung’s disease.

Methods

Five cases of definitive IASA were collected from a nationwide retrospective cohort study conducted from 2001 to 2010 and a search of the Japanese literature.

Results

Symptoms developed during the neonatal period in two patients, during early childhood in two, and at school age in one. Symptoms included abdominal distension with severe constipation (n = 4) and enterocolitis (n = 1). Rectocolonography showed megarectum and no narrow segment in most of the patients. All patients were negative for rectosphincteric reflex. The presence of ganglion cells was demonstrated by H&E or AChE staining from rectal mucosal biopsies or resected full-thickness segments. Two patients were treated conservatively, and three were treated surgically by internal anal sphincter myotomy (n = 2) or Lynn procedure (n = 1), with satisfactory outcomes.

Conclusion

IASA is a rare but distinct entity in Japan. Although the clinical features of IASA resemble those of short- and ultrashort-segment HD, characteristic pathological findings include the presence of ganglion cells. The outcomes of both conservative and surgical treatment are good.

     

The management of sportsman’s groin hernia in professional and amateur soccer players: a revised concept

Background

Chronic groin pain appears in athletes with a diverse etiology. In a select few, it can be defined as a sportsman’s hernia, that may be related, among other pathologies, to weakness of the posterior inguinal wall and may successfully respond to surgery.

Hypothesis

Surgical repair of the sportsman’s hernia is associated with good functional outcomes, if the diagnosis is based on meticulous examination and follows a simple selection flowchart.

Study design

Prospective case cohort study.

Methods

The study assessed patients recruited from 2006 until the present assessed by a dedicated team with clinical and radiographic features of a sportsman’s hernia who had failed a specified period of conservative therapies. Surgery was performed using a tension-free mesh open inguinal hernia repair.

Results

Of 246 male patients with chronic groin pain, 51 underwent surgery (mean age 20.7 years, range 14–36 years) with 58 inguinal procedures performed. Of the operated group, seven underwent bilateral surgery with a direct hernia found in 9/58 operated sides (15.5 %), an indirect hernial sac in 8/58 (14 %) and a direct and indirect hernia being found in 3/58 (5 %) of operated sides. There was no post-operative morbidity (median follow-up 36.1 months; range 1–74 months), with two failures (3.45 % of operated sides). All other patients were asymptomatic, returned to full sports activity within 4.3 weeks (range 3–8 weeks) after surgery, and required no analgesics or further treatment.

Conclusion

Selective surgical hernia repair, based on meticulous anamnesis and physical examination is effective in the management of chronic groin pain in athletes.

     

Trends in the incidence of hip fracture in Japan, 1987–1997: The third nationwide survey

The third nationwide survey for hip fracture incidence was conducted in 1997 following the first such survey in 1987 and the second in 1992. The purpose of this study was to investigate the trends in the incidence and regional distribution of this disease during 10 years. Of 10 271 orthopedic institutions in Japan, 4503 were selected as subjects for the study using the optimum allocation method. Questionnaires concerning new patients with hip fracture were mailed. The replies were obtained from 2930 institutions by the end of December 1998; the response rate was 65.1%. The number of new patients was estimated to be 89 900–94 900 [mean, 92 400; 20 100–21 400 (20 800) men and 69 600–73 600 (71 600) women]. The number of cases in 1997 was about 1.7 times higher than that in the first survey and 1.2 times higher than that in the second survey. The age-specific incidence (per 10 000 per year) in men and women in 1997 was 0.30 and 0.13, respectively, for age under 40 years; 0.91 and 0.60, 40–49 years; 2.00 and 2.39, 50–59 years; 5.12 and 9.07, 60–69 years; 17.3 and 40.8, 70–79 years; 57.4 and 147.8, 80–89 years; and 128.9 and 281.0, for age over 90 years. The incidence was increased compared with that of the first survey, and similar to the second survey, excepting that of women aged 80 years or older. Concerning regional differences, hip fracture incidence was relatively low in the eastern area compared to the western area in Japan, which was a trend identical to that in the previous nationwide surveys. Received: Aug. 7, 1999 / Accepted: Oct. 12, 1999     

Hospital volume and outcomes of cardiothoracic surgery in Japan: 2005–2009 national survey

Objectives

To elucidate the relationship between hospital volume and cardiothoracic surgical outcomes in Japan using the annual survey data, obtained between 2005 and 2009, collected by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery.

Methods

The relationship between hospital volume and 30-day mortality was analyzed using a logistic regression model. The empirical Bayes (EB) method was also used to stabilize any large variation resulting from a small sample size. Hospitals, whose lower limit of the EB mortality 95?% confidence interval was above the mean EB mortality of all hospitals, were defined as those with ??inferior outcomes??. The surgical procedures analyzed were coronary artery bypass grafting (CABG: elective?+?emergency), elective CABG, emergency CABG, single-valve surgery, surgery for acute type A dissection, open heart surgery for newborns, open heart surgery for infants, surgery for lung cancer, and surgery for esophageal cancer.

Results

There were large variations in 30-day mortality for all procedures, particularly in the lower-volume hospitals. There was a significant but weak inverse correlation between the hospital volume and the 30-day mortality rate for elective CABG, emergency CABG, single valve surgery, surgery for acute type A dissection, and lung cancer surgery. There was no correlation between hospital volume and the 30-day morality for open heart surgery for newborns and infants, and esophageal cancer surgery. After EB method adjustment, there was no hospital with inferior outcomes for conventional operations such as elective CABG, single-valve surgery and lung cancer surgery. The ratio of hospitals with inferior outcomes in more complex procedures was 1.8?% for open heart surgery for newborns, 0.8?% for open heart surgery for infants, and 0.2?% for esophageal cancer surgery.

Conclusion

There is a weak or no inverse correlation between the hospital volume and the mortality in cardiothoracic surgery in Japan. Most of the low-volume hospitals are not associated with inferior outcomes. The performance of the lower-volume hospitals should be carefully scrutinized using risk adjustment.     

TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial

Background

Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain.

Methods

Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)].

Results

A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13–0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09–0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups.

Conclusions

Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients’ ability to perform strenuous activities such as sports more than TEP patients.     

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

Background

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.

Methods

This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).

Results

Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and “atypical” extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.

Conclusions

Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.     

The outcomes of transanal endorectal pull-through for Hirschsprung’s disease according to the mucosectomy-commencing points: A study based on the results of a nationwide survey in Japan

Background/AimAlthough the mucosectomy-commencing points on transanal endorectal pull-through (TAEPT) differ among reports, the optimal point is unclear. This study assessed the outcomes among different mucosectomy-commencing points.MethodsWe conducted a nationwide survey from 2008 to 2012. The data of 1,087 Hirschsprung’s disease patients were collected, and data on those who underwent TAEPT were extracted. The patients were divided according to the mucosectomy-commencing points into two groups: in Group A, mucosectomy was started ≥ 5 mm from the dentate line (DL), and in Group B, mucosectomy was started < 5 mm from the DL. The extent of the aganglionic segment and postoperative complications in the month after TAEPT were compared.ResultsThe data of 327 patients were extracted (Group A, n = 155; B, n = 172). Aganglionosis extending to the sigmoid colon was the most frequent in both groups. Regarding postoperative complications, the patients of each group experienced enterocolitis (Group A: 8.4%; B: 7.6%) and incontinence (A: 3.9%; B: 2.9%). The incidence of rectal mucosal prolapse was significantly greater in Group B (4.1%); (A: 0%, p = 0.02).ConclusionsAlthough the outcomes of TAEPT were comparable in both groups, rectal mucosal prolapse was significantly frequent in patients in whom the commencing point was < 5 mm from the DL.Type of studyRetrospective studyLevel of evidenceLevel III     

Adjustable gastric band surgery or medical management in patients with type 2 diabetes and obesity: three-year results of a randomized trial

BackgroundFew randomized trials have compared surgical versus lifestyle and pharmacologic approaches for type 2 diabetes (T2D) patients with mild to moderate obesity.ObjectivesThis study examined resolution of hyperglycemia (A1C <6.5% and fasting glucose <126 mg/dL) 3 years after randomization to either a laparoscopic adjustable gastric band (LAGB) or 1-year diabetes and weight management (DWM) program.SettingUniversity medical center, United States.MethodsForty T2D patients (mean ± SD: age, 51.3 ±10.0 yr; weight 109.5 ± 15.0 kg; body mass index [BMI] 36.5 ± 3.7 kg/m²; HBA1C 8.2% ± 1.2%) were randomized to LAGB (n = 18) or DWM (n = 22).ResultsAt 3 years, 13% of 16 patients in LAGB and 5% of 17 patients in DWM achieved resolution of hyperglycemia (P = .601), with a modestly greater reduction in antidiabetic medications in the surgical group (P = .054). Reductions from baseline in A1C were sustained at 3 years in LAGB (?.82% [95% CI: ?1.62 to ?.01], P = .046) compared with DWM (+.23% [95% CI: ?.57 to 1.03], P = .567). The surgical group had greater weight loss (?12.0 kg [95% CI: ?15.9 to ?8.1] versus ?4.8 [95% CI: ?8.6 to ?.9], P = .010). HDL-cholesterol increased more after surgery (P = .003), but changes in triglycerides, LDL-cholesterol, and blood pressure did not differ between treatments. Diabetes- and obesity-specific quality of life improved comparably with both therapies.ConclusionsAchievement of American Diabetes Association targets for glucose, lipids, and blood pressure was similar with both treatment strategies. LAGB leads to greater sustained weight loss and higher HDL cholesterol compared with a DWM program. These findings may help guide patients with T2D and obesity when exploring options for diabetes and weight management.