Failed prior rotator cuff repair is associated with worse clinical outcomes after reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared with RTSA for CTA with prior RCR.MethodsFrom 2006 to 2014, all patients who underwent RTSA by two surgeons after failed RCR with minimum 2-year follow-up were identified. Patients who underwent RTSA with failed prior RCR were matched in a 1:1 ratio to patients undergoing primary RTSA, while controlling for demographic factors, prosthesis design, and surgeon. Postoperative active forward elevation and active external rotation were recorded. Outcome measures included American Shoulder and Elbow Surgeons score, Visual Analog Scale (VAS), and Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were noted, and comparative multivariate analysis was performed.ResultsOf 262 patients, 192 (73.3%) were available at minimum 2-year follow-up. The prior RCR group had a significantly higher complication rate (17.4%, n = 15) than the primary RTSA group (3.8%, n = 4) (P = .001), although no significant difference in periprosthetic infection (P = .469) or secondary revision rate (P = .136) was observed. At mean 36.3 ± 26.1-month follow-up, the prior RCR group had statistically worse American Shoulder and Elbow Surgeons score (P < .001), VAS (P = .001), Simple Shoulder Test (P < .001), and active forward elevation (P = .006). Patients with multiple failed RCR attempts (n = 38) before RTSA demonstrated no significant differences versus isolated failed RCR (n = 48; P > .05).ConclusionThis study demonstrated that patients with RTSA after prior failed RCR have significantly worse patient-reported outcomes and greater rate of perioperative complications than patients undergoing primary RTSA for CTA.     

Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery

BackgroundAlternative reservoir placement is increasingly popular during inflatable penile prosthesis (IPP) surgery to prevent intraperitoneal positioning, bowel, bladder, or vascular injury in patients with prior pelvic surgeries. Counter incision (CI) can be used for submuscular reservoir placement in high risk patients, however series exploring the safety remain limited.MethodsA database of IPP surgeries was queried for use of a CI during reservoir placement to compare 90-day clinical outcomes in a retrospective case-control study. Primary outcome was device infections, with secondary outcomes including reservoir herniation, hematoma, device malfunction rates, and operative times. Groups were compared using Kruskal-Wallis and Chi-Squared tests, with multivariate logistic regression models to identify predictors of infectious complications.ResultsA total of 534 cases met criteria, of which 51 (9.6%) used a CI for reservoir placement. The CI cohort included significantly more removal and replacements, 45.1% vs. 20.9% (P<0.001). Thirty-one CI patients (61.0%) had undergone prior prostatectomy compared to 134 (27.7%) non-CI patients (P=0.001). The most common reasons for CI were prior prostatectomy and inguinal hernia repair. Median operative time was 17 minutes longer in the CI group (74 vs. 57 minutes, P<0.001). Device infection rates were similar (2.0% vs. 4.1%, P=0.71), as were rates of hematoma (5.9% vs. 2.7%, P=0.19), and device malfunction (0.0% vs. 1.4% P=1.00).ConclusionsComplication rates were similar between CI and non-CI cohorts, even in a subset where approximately half the cases were removal and replacements. For physicians not comfortable with alternative placement through a penoscrotal or infrapubic incision, this offers a reasonable alternative and permits use of three-piece devices in patients with a hostile pelvis.     

Treatment Patterns and Outcomes for Patients with Adrenocortical Carcinoma Associated with Hospital Case Volume in the United States

Background

Adrenocortical carcinoma (ACC) is a rare, aggressive disease with no apparent change in treatment or survival in the United States over the past two decades. Our objective was to determine whether treatment patterns or clinical outcomes vary by hospital case volume.

Methods

Patients with ACC were identified from the National Cancer Database (1998–2011). High-volume centers (HVCs) were defined by a case load of ≥4 cases of primary adrenal malignancy annually, which corresponded to the 90th percentile. All other facilities were considered low-volume centers (LVCs).

Results

A total of 2,765 ACC patients were treated across 1,046 facilities. Compared to patients treated at LVCs, patients treated at HVCs were younger (50 vs. 54 years), with larger tumors (11.2 vs. 10.5 cm), and underwent higher rates of surgery (78.8 vs. 73.4 %), radical resection (17.3 vs. 13.9 %), regional lymph node evaluation (23.2 vs. 18.8 %), and chemotherapy including mitotane (43.8 vs. 31.0 %, all p < 0.05).There were no significant differences in median length of stay (5 vs. 5 days), 30-day readmission rates (4.0 % for HVCs vs. 3.9 % for LVCs), or 30-day postoperative mortality rates (1.9 % for HVCs vs. 3.7 % for LVCs). Median overall survival was 2.0 years for HVCs and 1.9 years for LVCs, p = 0.53. After adjusting for patient and tumor characteristics, overall survival did not differ significantly between patients treated at HVCs versus LVCs [HR = 0.89 (95 % confidence interval 0.70, 1.12)].

Conclusions

Treatment at HVCs was associated with more aggressive surgical resection and chemotherapy use. Prognosis remained poor despite more aggressive treatment.     

Tetrameric Immune Macroglobulins in Three Orders of Bony Fishes

The immune IgM-like macroglobulins were isolated from three species of bony fishes (Ictalurus punctatus, Lepisosteus osseus, and Polyodon spathula) representing the three orders of the subclass Actinopterygii. These macroglobulins were found to have sedimentation coefficients of 14 S and molecular weights of 600,000-630,000. The carbohydrate compositions were determined and found to be different from that of human macroglobulins. After reduction and alkylation, the heavy and light chains could be separated by gel filtration and were found to have molecular weights of approximately 70,000 and 23,000 respectively. The amino acid compositions of these chains were similar to those of mammalian IgM heavy and light chains. The macroglobulins were found by electron microscopy to have a tetrameric structure, in contrast to the pentameric structure found in mammalian, chicken, and shark IgM, i.e. in species later on the evolutionary scale.     

Conservative Beliefs,Male Gender,and Beliefs About Means Safety Among Firearm Owners

Cognitive Therapy and Research - Reducing access to highly lethal methods for suicide (i.e., means safety) has been promoted as a way to reduce suicide risk. Research by Anestis et al. (J Affect...     

Short photoperiod restores ventral subicular lesion-induced deficits in affective and socio-cognitive behavior in male Wistar rats

Photoperiod (day-length) has enduring effects on an organism's physiological functions like metabolism and behavioral phenotypes including cognition and affect. Circadian rhythm manipulations are potentially effective non-pharmacological strategies in the management of central nervous system insults. In our previous study, we demonstrated the efficacy of short photoperiod regime (SPR; 06/18 hr light-dark cycle) in establishing functional recovery in ventral subicular lesion (VSL) rats. The present study further demonstrates the efficacy of SPR in mitigating anxiety and depression as well as facilitating socio-cognitive behavior in VSL rats. VSL elevated the basal plasma corticosterone levels, increased anxiety, anhedonia, and behavioral despair with decreased self-care. The VSL rats also exhibited a considerable degree of impaired social cognition, in terms of altered social preference and social novelty. Exposure to SPR for 21 days mitigated the anxiety- and depressive-like phenotypes as well as improved social cognition significantly. Thus, the study demonstrated the effectiveness of SPR strategy in reversing most of the behavioral deficits caused by VSL. SPR, perhaps, would have regulated the hypothalamo-pituitary-adrenal axis responsiveness as we observed a decrease in plasma corticosterone levels following SPR in VSL rats. The study implies the need for developing a task-dependent SPR strategy to achieve complete behavioral recovery as the functional demands of each behavior is distinct. In summary, the study highlights the efficacy of photoperiod manipulation as a novel, non-pharmacological approach in mitigating the affective and cognitive deficits associated with neuropsychiatric disorders such as bipolar disorder and Alzheimer's disease wherein circadian rhythm alterations are implicated.