The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries.

AIMS: Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients. METHODS AND RESULTS: Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded. CONCLUSION: CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.     

Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy

Background:

Severe crouch gait in adolescent cerebral palsy is a difficult problem to manage. The patients develop loading of patellofemoral joint, leading to pain, gait deviation, excessive energy expenditure and progressive loss of function. Patella alta and avulsion of patella are the other complications. Different treatment options have been described in the literature to deal with this difficult problem. We evaluated outcome of supracondylar femoral extension osteotomy (SCFEO) and patellar tendon advancement (PTA) in the treatment of crouch gait in patients with cerebral palsy.

Materials and Methods:

Fourteen adolescents with crouch gait were operated by SCFEO and PTA. All subjects were evaluated pre and postoperatively. Clinical, radiographic, observational gait analysis and functional measures were included to assess the changes in knee function.

Results:

Cases were followed up to 3 years. The patients walked with increased knee extension and improvement in quadriceps muscle strength. Knee pain was decreased and improvements in functional mobility and radiologic improvement were found.

Conclusion:

SCFEO and PTA for adolescent crouch gait is effective in improving knee extensor strength, reducing knee pain and improving function.     

Calciotropic hormones and the risk of hip and nonspine fractures in older adults: the Health ABC Study

The effects of vitamin D and parathyroid hormone (PTH) levels on incident fracture remain uncertain. To test the hypothesis that increasing serum 25‐hydroxyvitamin D [25(OH)D] and decreasing PTH levels are associated with decreased risk of hip and any nonspine fracture, we conducted a prospective cohort study among 2614 community‐dwelling white and black participants, aged ≥70 years, from the Health, Aging and Body Composition (Health ABC) Study. Serum and plasma samples were drawn at year 2, which formed the baseline for this analysis. Serum 25(OH)D and intact PTH (1‐84) were measured using radioimmunoassay with DiaSorin reagents and EDTA plasma with a two‐site immunoradiometric assay kit, respectively. Incident fractures (hip and any nonspine) were assessed after year 2, every 6 months, by self‐report and validated by radiology reports. The median (interquartile range) follow‐up times for hip and any nonspine fractures were 6.4 (6.1–6.5) and 6.4 (5.5–6.5) years, respectively. Cox proportional hazards regression was used to estimate the hazard ratios (HR) with 95% confidence intervals (CI) for fracture. There were 84 hip and 247 nonspine fractures that occurred over the follow‐up period. The multivariable adjusted HRs (95% CIs) of hip fracture for participants in the lowest (≤17.78 ng/mL), second (17.79 to 24.36 ng/mL), and third quartiles (24.37 to 31.94 ng/mL) of 25(OH)D were 1.92 (0.97 to 3.83), 0.75 (0.32 to 1.72) and 1.86 (1.00 to 3.45), respectively, compared with participants in the highest 25(OH)D quartile (>31.94 ng/mL) (p trend = 0.217). Additional adjustment for IL‐6 (p = 0.107), PTH (p = 0.124), and hip areal bone mineral density (p = 0.137) attenuated HRs of hip fracture in the lowest quartile by 16.3%, 17.4%, and 26.1%, respectively. There was no evidence of an association between 25(OH)D and any nonspine fractures, or between PTH and hip or any nonspine fractures. We found limited evidence to support an association between calciotropic hormones and hip and nonspine fractures in older men and women. © 2012 American Society for Bone and Mineral Research.     

Propeller DICAP flap for a large defect on the back—Case report and review of the literature

Reconstruction of large soft tissue defects of the back is a challenging problem. Large defects of the back were reconstructed with multiple random pattern or local pedicled muscle (and skin graft) or musculocutaneous flaps. The clinical use of perforator flaps has demonstrated that harvesting of flaps on a single perforator is possible for reconstruction of large defects. We present a 71‐year‐old male with a lesion on his left mid back that measured 10 × 10 × 4 cm³. Biopsy of the lesion was consistent with dermatofibrosarcoma protruberans. Wide local excision of the lesion with 4 cm margin was performed. The soft tissue defect, ～20 cm in diameter, was reconstructed with a large propeller dorsal intercostal artery perforator (DICAP) flap. The DICAP flap measured 40 × 15 cm² based on a single perforator—lateral branch of dorsal rami of the seventh posterior intercostal artery on the right side. The perforator flap was elevated at the subfascial level and transposed 180° into the defect. The donor site on the right side of the back was closed directly. This case illustrates the size of the propeller DICAP flap that could be safely harvested on a single perforator from the dorsal rami of the posterior intercostal artery. To our knowledge this is the largest reported pedicled perforator flap harvested on a single perforator on the posterior trunk. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Severe post-burn neck contracture release and skin graft harvest using tumescent local anaesthesia as the sole anesthetic technique

Severe post-burn contractures in the neck often cause anatomical distortion and restriction of neck movements, resulting in varying degrees of difficulty in airway management. Any mode of anesthesia that may obviate the need for imperative airway control may be desirable in such situations in which a difficult airway may be anticipated. Here we present one such situation where tumescent local anesthesia was employed to manage a case of severe post-burn neck contractures posted for contracture release and split-skin grafting. The other benefits of this method were minimal blood loss and excellent postoperative analgesia. In conclusion, it can be emphasized that the application of tumescent anesthesia is an important anesthetic tool in patients with predicted difficult airway management.