Closed reduction of constrained total hip arthroplasty

Many surgeons use acetabular components with constrained polyethylene liners to improve stability in patients with a history of hip dislocation. Considering that the reported incidence of hip dislocation in patients with constrained components is 4% to 29%, it generally is recognized that open reduction would likely be necessary in cases of redislocation. Recent reports have indicated that closed reduction of constrained total hip arthroplasty is possible in some cases. However, it is unknown whether closed reduction damages the constrained polyethylene liner and predisposes patients to additional dislocations. The current study evaluated the integrity of the polyethylene constraint mechanism after in vitro simulation of hip dislocation and closed reduction. After lever-out dislocation and reduction, 76% of the capture mechanism strength was maintained without additionally damaging the polyethylene liner. Also reported is the technique for closed reduction in patients with constrained components and a clinical series of six patients who had successful closed reduction. These patients remain stable without any additional dislocations 7 to 72 months after reduction. These data suggest that closed reduction of Poly-Dial constrained polyethylene liners can be successful without predisposing patients to additional dislocations.     

The Ohio Hospice Bereavement Study: meeting NHPCO standards

Little attention has been paid to documenting the quality and impact of hospice bereavement programs. While quality of life, quality of dying, and quality of end-of-life measures are common indicators of effective clinical service, they are not adequate gauges of quality from a bereavement perspective. The National Hospice and Palliative Care Organization (NHPCO) published standards for hospice and palliative care programs that included a section on bereavement care. Little evaluative work has been done to discover whether hospice programs nationwide are compliant with these standards. The purpose of this study was to evaluate whether hospice programs (n = 32) in the state of Ohio were meeting the NHPCO bereavement standards. Findings indicated that the participating hospice programs were 83 percent compliant at least some of the time.     

Bowel injury: current and evolving management strategies

The intestine is often dose limiting during abdominal and pelvic radiation therapy. Delayed bowel toxicity is difficult to manage and adversely impacts the quality of life of long-term cancer survivors. Of the 8 to 9 million cancer survivors currently living in the United States, more than half have had abdominal or pelvic tumors, and about 60% of these patients have undergone or will undergo radiation therapy. Therefore, interventions that limit postradiation intestinal dysfunction would significantly improve outcomes in a large number of patients. Worthwhile steps toward reducing toxicity of treatments have been taken recently by introducing dose-sculpting treatment techniques. However, prophylactic or therapeutic approaches derived from an improved understanding of the pathophysiology of bowel injury will result in further advances. This article reviews current principles in the diagnosis and management of intestinal radiation injury. It also provides an overview of investigational strategies aimed at reducing radiation-induced bowel toxicity. These strategies include free radical scavengers, antioxidants, cytoprotective agents, cytokines, and enterotrophic interventions, as well as modulators of intraluminal factors, endothelial dysfunction, and neuroimmune interactions. Preclinical testing in clinically relevant animal models will facilitate translation of these strategies into the clinic and contribute to improving cancer cure rates and quality of life in cancer survivors.     

Antenatal assessment of the growth restricted fetus

Babies who are small due to intrauterine growth restriction are at higher risk for poor perinatal and long-term outcome than those who are appropriately grown. Through multiple antenatal testing modalities a sequence of deteriorating fetal status can be documented in such cases. The nature of this compromise is best reflected by the combination of fetal biometry, biophysical profile scoring and arterial and venous Doppler. This combination accurately defines fetal states and therefore risk of stillbirth or poor transition to extrauterine life. In the preterm neonate, fetal factors, gestational age and neonatal course interact significantly to impact on short- and long-term outcomes. The potential for iatrogenic prematurity is great and ongoing appraisal of peripartum management is critical. An integrated management protocol accounting for these factors is examined in this review.     

Imprint cytology versus frozen section: intraoperative analysis of sentinel lymph nodes in breast cancer

Background: Intraoperative analysis of the sentinel node status in breast cancer adds the benefit of proceeding to axillary dissection at the same time as the primary breast operation, without the need for a second trip to theatre. However, the method of intra­operative analysis must be both rapid and accurate for use in this setting. Methods: A prospective series of 20 consecutive patients in one hospital who underwent sentinel node biopsy was performed. Intraoperative evaluation by imprint cytology and frozen section was compared with the final histopathological results. The time taken for both procedures was recorded. Results: A total of 21 sentinel node procedures was performed. The sentinel node was found in 20 procedures (95%). The average time to perform intraoperative pathological analysis was 17 min (range: 5?35 min). Of the eight positive sentinel nodes, five were positive on imprint cytology alone and five were positive on frozen section alone (62.5% accuracy). The statistical false negative rate was 18.8% and the ‘false reassurance rate’ (patients with an initially negative node that was subsequently positive on formal histology who required a second trip to theatre for axillary dissection) was 37.5%. All patients with a negative sentinel node had a negative axilla. Conclusions: Intraoperative analysis of sentinel lymph nodes in breast cancer can be performed quickly. Imprint cytology and frozen section show comparable accuracy in predicting sentinel node status.     

Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization

Background: Sentinel node biopsy (SNB) for breast cancer patients is a new technique with the potential to provide an accurate staging of the axillary nodal status while avoiding the morbidity of an axillary dissection. The objective of the present study is to validate the use of sentinel node biopsy in a New Zealand hospital and to compare the ability of patent blue dye (PB) alone with triple modality (TM) (preoperative lymphoscintigraphy, intraoperative gamma probe and intraoperative blue dye) to identify the sentinel node. Methods: A total of 104 patients who had a palpable breast lump that was confirmed to be malignant by radiology and cytology and a clinical diagnosis of stage I or stage II breast cancer, were enrolled for SNB and randomly assigned to triple modality or blue dye alone for the localization of the sentinel node. Axillary dissection was performed after the sentinel node(s) had been removed. Results: There were 63 patients in the PB group and 41 patients in the TM group. Both groups are comparable, with a similar mean age and primary tumour size. A sentinel node was identified in 57 (90%) of the PB group patients and 40 (98%) of the TM group patients. Of these 23 (37%) of the PB group and 23 (56%) in the TM group had axillary nodes positive for malignancy. There was one false negative SNB in the PB group and two false negative results in the TM group. Therefore, the PB group had an accuracy of 98% and a sensitivity of 96% compared to an accuracy of 95% and a sensitivity of 91% for the TM group. Conclusion: The results of the present study validate the use of SNB in suitable breast cancer patients. Identification and the accuracy of the sentinel node localization were similar between the two groups. Therefore, in hospital centres without adequate access to a nuclear medical facility, it would be feasible to conduct SNB using blue dye alone.     

Interpreting Results in Mental Health Research

It is often difficult to interpret the clinical or policy significance of findings from mental health research when results are presented only in terms of statistical significance. Results expressed in terms of p values or as a metric corresponding to a mental health status scale are seldom intuitively meaningful. To help interpret the significance of research results, we demonstrate a social validity approach that relates scores on mental health status scales to four subsequent major life events. A logistic regression model is used to estimate the relation between mental health status scores and the probability of subsequent major life events, using data obtained on Medicaid beneficiaries with schizophrenia from an evaluation of the Utah Prepaid Mental Health Plan. Using this relatively simple approach will demonstrate to policy makers, clinicians, and researchers the social impact of an outcome, thereby aiding in the interpretation of the significance of results.     

Low proliferative rate of invasive node-negative breast cancer predicts for a favorable outcome: a prospective evaluation of 669 patients

This study was designed to compare outcome in terms of disease-free survival (DFS) in women with histologically negative axillary lymph nodes and documented low proliferative rate cancer to other well-defined prognostic factors including type of adjuvant treatment. Between 1988 and 1998, we studied 669 patients with invasive node-negative breast cancer up to 5 cm in size and low proliferative rate measured by flow cytometry to determine S-phase fraction (SPF) or by histochemistry (Ki67/MIB1). At a median follow-up of 53 months, 5-year DFS for the entire group was 94% and did not differ significantly by type of systemic adjuvant treatment: none (133 patients, 95% DFS), tamoxifen (441 patients, 94% DFS), or chemotherapy with doxorubicin and cyclophosphamide (95 patients, 92% DFS). In a multivariate prognostic factor analysis, only tumor size was significant; 5-year DFS was 96% for T1N0 cancer versus 89% for T2N0 cancer (P = 0.01). We have prospectively confirmed that a low rate of proliferation as measured by SPF or MIB1 determination confers an excellent prognosis in invasive node-negative breast cancer up to 5 cm in size, regardless of adjuvant treatment.