Exeter Short Stems Compared With Standard Length Exeter Stems : Experience From the Australian Orthopaedic Association National Joint Replacement Registry

The standard Exeter stem has a length of 150 mm with offsets 37.5 to 56 mm. Shorter stems of lengths 95, 115 and 125 mm with offsets 35.5 mm or less are available for patients with smaller femurs. Concern has been raised regarding the behavior of the smaller implants. This paper analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry comparing survivorship of stems of offset 35.5 mm or less with the standard stems of 37.5 mm offset or greater. At 7 years, there was no significant difference in the cumulative percent revision rate in the short stems (3.4%, 95% CI 2.4-4.8%) compared with the standard length stems (3.5%, 95% CI 3.3-3.8%) despite its use in a greater proportion of potentially more difficult developmental dysplasia of the hip cases.     

Major Perioperative Morbidity Does Not Affect Long-Term Survival in Patients Undergoing Esophagectomy for Cancer of the Esophagus or Gastroesophageal Junction

Introduction

The incidence of cancer of the esophagus/GE junction is dramatically increasing but continues to have a dismal prognosis. Esophagectomy provides the best opportunity for long-term cure but is hampered by increased rates of perioperative morbidity. We reviewed our large institutional experience to evaluate the impact of postoperative complications on the long-term survival of patients undergoing resection for curative intent.

Methods

We identified 237 patients who underwent esophagogastrectomy, with curative intent, for cancer between 1994 and 2008. Complications were graded using the previously published Clavien scale. Survival was calculated using Kaplan–Meier methodology and survival curves were compared using log-rank tests. Multivariate analysis was performed with continuous and categorical variables as predictors of survival, and examined with logistic regression and odds ratio confidence intervals.

Results

There were 12 (5 %) perioperative deaths. The average age of all patients was 62 years, and the majority (82 %) was male. Complication grade did not significantly affect long-term survival, although patients with grade IV (serious) complications did have a decreased survival (p = 0.15). Predictors of survival showed that the minimally invasive type esophagectomy (p = 0.0004) and pathologic stage (p = 0.0007) were determining factors. There was a significant difference in overall survival among patients who experienced pneumonia (p = 0.00016) and respiratory complications (p = 0.0004), but this was not significant on multivariate analysis.

Conclusions

In this single-institution series, we found that major perioperative morbidity did not have a negative impact on long-term survival which is different than previous series. The impact of tumor characteristics at time of resection on long-term survival is of most importance.     

Operability and early outcome in 48 Irish patients with peritoneal malignancy treated by surgery and intraperitoneal chemotherapy in a specialized centre

BackgroundIn selected cases of peritoneal malignancy a novel approach of complete macroscopic tumour removal by extensive surgical cytoreduction, combined with intraperitoneal chemotherapy, provides a possibility of cure. The experience with 48 consecutive Irish cases undergoing laparotomy in a specialized centre is reported.Patients and methodsA subset of 48 Irish patients out of a total of 120 cases with peritoneal malignancy underwent surgery between September 1999 and March 2011 in an English National referral centre. Overall 37/48 (77%) had appendiceal mucinous tumours with pseudomyxoma peritonei type syndrome. The treatment strategy involved macroscopic complete tumour removal (complete cytoreduction) combined with intra-operative, intraperitoneal chemotherapy.ResultsOverall 30/48 (62.5%) had complete cytoreduction, 15/48 (31.3%) had major debulking and 3 (4.2%) had laparotomy and biopsy only. The median (range) operating time in hours was 9.8 (4.8–16) in the 30 who had complete cytoreduction compared with 6.3 (4.5–11) in the 15 who had debulking (p = 0.019). There was no post-operative mortality.Overall five year survival for the complete tumour removal group was 66% compared with 12% for those only amenable to major debulking.ConclusionThis novel strategy of cytoreduction combined with intraperitoneal chemotherapy is effective in selected patients with peritoneal malignancy. The complex surgery is particularly effective for appendiceal tumours and provides the only possibility of cure in this challenging disease.     

Frames of reference for eye–head gaze shifts evoked during frontal eye field stimulation

The frontal eye field (FEF), in the prefrontal cortex, participates in the transformation of visual signals into saccade motor commands and in eye–head gaze control. The FEF is thought to show eye‐fixed visual codes in head‐restrained monkeys, but it is not known how it transforms these inputs into spatial codes for head‐unrestrained gaze commands. Here, we tested if the FEF influences desired gaze commands within a simple eye‐fixed frame, like the superior colliculus (SC), or in more complex egocentric frames like the supplementary eye fields (SEFs). We electrically stimulated 95 FEF sites in two head‐unrestrained monkeys to evoke 3D eye–head gaze shifts and then mathematically rotated these trajectories into various reference frames. In theory, each stimulation site should specify a specific spatial goal when the evoked gaze shifts are plotted in the appropriate frame. We found that these motor output frames varied site by site, mainly within the eye‐to‐head frame continuum. Thus, consistent with the intermediate placement of the FEF within the high‐level circuits for gaze control, its stimulation‐evoked output showed an intermediate trend between the multiple reference frame codes observed in SEF‐evoked gaze shifts and the simpler eye‐fixed reference frame observed in SC‐evoked movements. These results suggest that, although the SC, FEF and SEF carry eye‐fixed information at the level of their unit response fields, this information is transformed differently in their output projections to the eye and head controllers.     

Determining optimal prostate-specific antigen thresholds to identify an increased 4-year risk of prostate cancer development: an analysis within the Veterans Affairs Health Care System

Purpose

To assess the prostate-specific antigen (PSA) threshold value that optimally predicts future risk of prostate cancer (overall and by race) for a dispersed US population.

Methods

This was a retrospective analysis of men in the Veterans Affairs (VA) Health Care System database. Men ≥ 40 years with a baseline PSA ≤ 4.0 ng/mL, not receiving 5-alpha reductase inhibitors, and without a prostate cancer diagnosis prior to baseline PSA date were included and followed for 4 years. Patients diagnosed with prostate cancer within 6 months of baseline were excluded. The optimal PSA threshold value for future 4-year prostate cancer risk was determined by maximizing Youden’s index.

Results

The eligible population for the final analysis included 41,250 Caucasian (n = 24,518; 59.4 %) and African American (n = 16,732; 40.6 %) patients. The 4-year prostate cancer rate was 3.08 % overall, and race-specific rates were 3.02 and 3.17 % for Caucasian and African American men, respectively. Mean time to prostate cancer diagnosis was 2.01 years across all patients. Race-specific PSA thresholds that optimally predicted future prostate cancer were 2.5 ng/mL [area under the curve (AUC) = 80.3 %] in Caucasians and a 1.9 ng/mL (AUC = 85.4 %) in African Americans; across all patients, a 2.4 ng/mL threshold was optimal (AUC = 82.5 %).

Conclusions

In the VA population, a relatively low PSA threshold of ~2.5 ng/mL was optimal in predicting prostate cancer within 4 years overall and for Caucasian men, but an even lower threshold of 1.9 ng/mL was applicable for African American men.

     

Using transprofessional care in the emergency department to reduce patient admissions: A retrospective audit of medical histories

The demand for emergency department (ED) services has increased significantly, due to our increasingly ageing population and limited access to primary care. This article reports outcomes from a transprofessional model of care in an ED in Victoria, Australia. Nurses, physiotherapists, social workers, and occupational therapists undertook additional education to increase the range of services they could provide and thereby expedite patient flow through the ED. One hundred patients who received this service were matched against 50 patients who did not. The most common reasons for patient admission were limb injury/limb pain (n = 47, 23.5%) and falls (n = 46, 23.0%). Transprofessional interventions included applying supportive bandages, slings, zimmer splints and controlled ankle motion (CAM) boots, and referral to new services such as case management and mental health teams. The rate of hospital admissions was significantly lower in the transprofessional group (n = 27, 18.0%) than in the reference group (n = 19, 38%, p = 0.005). This group also had a slightly lower re-presentation rate (n = 4, 2.7%) than patients in the reference group (n = 2, 4.0%). There are many benefits that support this model of care that in turn reduces ED overcrowding and work stress. A transprofessional model may offer a creative solution to meeting the varied needs of patients presenting for emergency care.     

The use of HPV Linear Array Assay for multiple HPV typing on archival frozen tissue and DNA specimens

Accurate HPV typing is important for natural history and epidemiology studies. With the introduction of prophylactic multivalent HPV vaccines, there is also the need to determine the dominant genotypes in different populations and the effect of a vaccination programme on infection profiles. The interplay between multiple infection, viral persistence and implementation of interventions is a complicated one and therefore requires a reliable and accurate HPV detection and typing method. The Linear Array HPV genotyping test is a PCR-based HPV detection kit which can detect qualitatively Multiple HPV Infection in cervical cells collected in PreservCyt Solution. The utility of this kit for multiple HPV typing of archival frozen tissue and cervical cells not collected in PreservCyt are described.