Vancouver B2 Peri-Prosthetic Fractures in Cemented Femoral Implants can be Treated With Open Reduction and Internal Fixation Alone Without Revision

BackgroundThe aim of this study is to assess the outcomes of 52 consecutive Vancouver B2 peri-prosthetic fractures around cemented polished double-tapered stems treated by open reduction and internal fixation in 2 trauma centers in 2 countries.MethodsOutcomes included modified Harris Hip Score (mHHS), Harris Pain Score, and return to pre-injury mobility. Fracture healing was assessed; implant subsidence measured and complications including re-operations reported.ResultsNo patient was lost to follow-up. Median patient age at operation was 82 years (range 43-98); Harris pain scores showed minimal pain (median 42, range 10-44) at latest follow-up. Median total subsidence at 1 year was 1.1 mm (range 0-5.4), the majority of which occurred within the cement mantle. No subsequent femoral stem revision was required (median 2.9 years, 0-10); however, there were 3 re-operations: 1 re-operation for pre-existing recurrent dislocation involving head liner exchange and 2 for repeat fixation due to metal fatigue. Two additional fractures occurred below the new plating, requiring further plating whilst still retaining the original stems.ConclusionAnatomical reduction and open reduction and internal fixation of Vancouver B2 peri-prosthetic fractures should be considered as an appropriate treatment solution for frail elderly patients with a peri-prosthetic fracture around cemented polished double-tapered stems.     

Pharmacogenetics of the systemic treatment in advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) accounts for the majority of primary liver cancers. To date, most patients with HCC are diagnosed at an advanced tumor stage, excluding them from potentially curative therapies (i.e., resection, liver transplantation, percutaneous ablation). Treatments with palliative intent include chemoembolization and systemic therapy. Among systemic treatments, the small-molecule multikinase inhibitor sorafenib has been the only systemic treatment available for advanced HCC over 10 years. More recently, other smallmolecule multikinase inhibitors (e.g., regorafenib, lenvatinib, cabozantinib) have been approved for HCC treatment. The promising immune checkpoint inhibitors (e.g., nivolumab, pembrolizumab) are still under investigation in Europe while in the US nivolumab has already been approved by FDA in sorafenib refractory or resistant patients. Other molecules, such as the selective CDK4/6inhibitors (e.g., palbociclib, ribociclib), are in earlier stages of clinical development, and the c- MET inhibitor tivantinib did not show positive results in a phase III study. However, even if the introduction of targeted agents has led to great advances in patient response and survival with an acceptable toxicity profile, a remarkable inter-individual heterogeneity in therapy outcome persists and constitutes a significant problem in disease management. Thus, the identification of biomarkers that predict which patients will benefit from a specific intervention could significantly affect decision-making and therapy planning. Germ-line variants have been suggested to play an important role in determining outcomes of HCC systemic therapy in terms of both toxicity and treatment efficacy. Particularly, a number of studies have focused on the role of genetic polymorphisms impacting the drug metabolic pathway and membrane translocation as well as the drug mechanism of action as predictive/prognostic markers of HCC treatment. The aim of this review is to summarize and critically discuss the pharmacogenetic literature evidences, with particular attention to sorafenib and regorafenib, which have been used longer than the others in HCC treatment.     

Neurovascular emergencies: imaging diagnosis and neurointerventional treatment

Neurovascular emergencies, consisting of acute ischemic stroke, non-traumatic aneurysmal subarachnoid hemorrhage, arteriovenous malformation, dural arteriovenous fistula, and carotid- cavernous fistula, can have an acute presentation to the emergency department. Radiologists should have an understanding of these processes and their imaging findings in order to provide a prompt and accurate diagnosis. Neurointerventional radiology plays a critical role in providing additional diagnostic information and potentially curative treatment. Understanding the grading scales used to evaluate and prognosticate these neurovascular emergencies can help expedite management for best possible patient outcomes.     

The prognostic and predictive value of sstr<Subscript>2</Subscript>-immunohistochemistry and sstr<Subscript>2</Subscript>-targeted imaging in neuroendocrine tumors

Purpose

Our aim was to assess the prognostic and predictive value of somatostatin receptor 2 (sstr₂) in neuroendocrine tumors (NETs).

Methods

We established a tissue microarray and imaging database from NET patients that received sstr₂-targeted radiopeptide therapy with yttrium-90-DOTATOC, lutetium-177-DOTATOC or alternative treatment. We used univariate and multivariate analyses to identify prognostic and predictive markers for overall survival, including sstr₂-imaging and sstr₂-immunohistochemistry.

Results

We included a total of 279 patients. In these patients, sstr₂-immunohistochemistry was an independent prognostic marker for overall survival (HR: 0.82, 95 % CI: 0.67 – 0.99, n?=?279, p?=?0.037). In DOTATOC patients, sstr₂-expression on immunohistochemistry correlated with tumor uptake on sstr₂-imaging (n?=?170, p?<?0.001); however, sstr₂-imaging showed a higher prognostic accuracy (positive predictive value: +27 %, 95 % CI: 3 – 56 %, p?=?0.025). Sstr₂-expression did not predict a benefit of DOTATOC over alternative treatment (p?=?0.93).

Conclusions

Our results suggest sstr₂ as an independent prognostic marker in NETs. Sstr₂-immunohistochemistry correlates with sstr₂-imaging; however, sstr₂-imaging is more accurate for determining the individual prognosis.

     

Genetic diversity study on 12 X-STR loci of investigator® Argus X STR kit in Bangladeshi population

The X-chromosome short tandem repeat (STR) loci are of particular interest for solving complex kinship and paternity cases. Here, we report the genetic data from 209 unrelated Bangladeshi individuals (102 males and 107 females) that were genotyped using the 12 X-chromosomal STR markers included in the Investigator® Argus X-12 kit (Qiagen). The 12 X-STR markers are located in four linkage groups (linkage group I: DXS10135, DXS10148, and DXS8378; linkage group II: DXS7132, DXS10079, and DXS10074; linkage group III: DXS10103, HPRTB, and DXS10101; and linkage group IV: DXS10146, DXS10134, and DXS7423). Allelic frequencies of the 12 X-STR loci and haplotype frequencies of the four linkage groups were investigated. No significant difference was observed in the allele frequencies of males and females. Distributions of heterozygosity were observed from 64.5 to 92.5% among the studied 12 X STR loci. DXS10135 and DXS10101 loci were found to be most polymorphic. For all the four linkage groups, the haplotype diversity was found to be greater than 0.986. A total of 95, 73, 66, and 74 haplotypes were observed in linkage groups I, II, III, and IV, respectively. Hardy–Weinberg equilibrium tests showed no significant deviation from expected values for all 12 loci (p > 0.05). The exact test for pairwise linkage disequilibrium for the 12 loci in the male samples did not show any significant linkage disequilibrium except the DXS10103 and DXS10101 loci after the p values were corrected by Bonferroni’s correction for multiple testing (p > 0.05/66). A combined power of discrimination in male and female individuals were 0.999999998159791 and 0.999999999999993, respectively. The combined mean exclusion chance were 0.999997635 in deficiency cases, 0.999999996 in normal trio cases, and 0.999999178 in duo cases. The currently investigated Bangladeshi population showed significant differences when compared with previously reported X-STR data from other 12 populations. The results of the data analysis indicated that all the loci in the Investigator® Argus X 12 kit were fairly informative and might be useful in forensic application and kinship analysis in Bangladeshi population.

     

Matrix‐Metalloproteinase‐2 Predicts Arteriovenous Fistula Failure in Hemodialysis Patients

In hemodialysis patients the principal cause of arteriovenous fistula dysfunction is stenosis. Matrix‐metalloproteinase‐2 is implicated in the pathophysiological mechanism of stenosis development. Our study tried to assess the clinical impact of this protease on arteriovenous fistula survival. Seventy‐nine prevalent dialysis patients with functional arteriovenous fistulas were included in the study. The presence of stenosis and the serum levels of matrix‐metalloproteinase‐2 were determined at the beginning of the study. The patency of the arteriovenous fistulas was followed‐ up for two years. In multivariate regression; matrix‐metalloproteinase‐2 was a significant predictor of vascular access loss (HR = 1.104, 95%CI 1.033–1.179, P = 0.003). Patients with a level of matrix‐metalloproteinase‐2 lower than 50 ng/mL had a better survival of the arteriovenous fistulas. Matrix‐metalloproteinase‐2 was an even stronger predictor of fistula failure in the stenosis group (HR = 1.076, 95%CI 1.027–1.127, P = 0.002). In our study matrix‐metalloproteinase‐2 has a predictive value for arteriovenous fistula failure.     

Is High‐Volume Online Hemodiafiltration Associated With Malnutrition?

Chronic malnutrition is a common problem in patients with end‐stage renal disease on hemodialysis. Some studies have reported albumin loss into dialysis fluid during postdilution online hemodiafiltration (OL‐HDF). The aim of the study was to assess the nutritional status of patients on high‐volume OL‐HDF and to demonstrate that higher convective clearances are not associated with malnutrition due to possible loss of nutrients with ultrafiltration. Demographic and clinical data, corporal composition with bioimpedance spectroscopy, dialysis features, albumin loss into dialysis fluid and laboratory parameters were collected in twenty‐eight patients with ESRD undergoing postdilution OL‐HDF with stable convective volumes over 28 L/session. Convective volume (CV) in the last six months was 32.51 ± 3.52 L per session. Cross‐sectional analysis of dialysis features showed 32.7 ± 3.34 L of CV and high reduction rates of beta‐2‐microglobulin (84.2 ± 3.8%) and cystatin‐C (81.6 ± 3.47%). Beta‐2‐microglobulin reduction showed a positive correlation with prealbumin levels (P = 0.048). CV was only correlated with cystatin‐C reduction (P = 0.025). Estimated albumin loss into dialysis fluid (1.82 ± 1.05 g/session) was not related to laboratory or bioimpedance nutritional parameters, or to CV. Among patients with higher CV, serum albumin levels maintained more stability during the observational period. High volume OL‐HDF results in better convective clearances and is not associated with malnutrition. Albumin and nutrients loss into dialysis fluid should not be a limiting factor of the substitution volume.     

Support workers as agents for health behavior change: An Australian study of the perceptions of clients with complex needs,support workers,and care coordinators

ABSTRACT

An expanding aging population has placed increased demands on health care resources in many countries. Enhancing community aged care support workers’ role to support greater client self-management and reablement is therefore timely. This article presents perceptions of the impact of an Australian practice change initiative designed to enhance knowledge, skills, and confidence of support workers to support behavior change in clients with complex health care needs. A comprehensive training program was delivered in 2013. Methods included thematic analysis of interviews with clients, focus groups with support workers and coordinators, and collection of case studies of client/support worker behavior change interactions. Client, support worker, and coordinator responses were highly positive, reporting improvement in the quality of interactions with clients, client health outcomes, care coordination, communication, and teamwork. Mental health literacy remained the biggest knowledge gap. This research showed that support workers are ideally placed to be more actively involved in motivating clients to achieve behavior change goals.