Slipped capital femoral epiphysis with severe vitamin D deficiency

Slipped capital femoral epiphysis is a relatively common disorder in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although clinicians have theorized that contributing factors to the development of slipped capital femoral epiphysis include 25-hydroxyvitamin D deficiency and other nutritional deficiencies, the roles of these factors have not been fully analyzed. This article presents a case of a morbidly obese 13-year-old African-American boy who presented with sudden worsening of chronic hip pain and was diagnosed with stable, bilateral, grade-III slipped capital femoral epiphysis and severe vitamin D deficiency. He was initially treated with bilateral single-screw percutaneous fixation, however, after continued pain and nonunion, a right valgus subtrochanteric osteotomy was performed in association with correction of his severe vitamin D deficiency. This procedure led to improvement of his hip function and successful resolution of the pain. Approximately 3 months after the second operation and vitamin supplementation, the patient had signs of union, and his weight bearing progressed without discomfort. Although the osteotomy provided substantial biomechanical advantage by changing the forces across the physis from shear to compressive, correction of the vitamin D deficiency was critical in providing metabolic capacity for bone healing. Vitamin D plays an important role in bone formation and development, but the level of 25-hydroxyvitamin D is not routinely measured during assessment and treatment of slipped capital femoral epiphysis patients. The early detection and proper treatment of vitamin D may assist in the treatment of patients with slipped capital femoral epiphysis.     

Coblation lesion formation in a porcine tongue model

Objective

To investigate, in a porcine tongue model, the lesions created by coblation to define the optimal application of this method in treating the enlarged tongue base in patients with obstructive sleep apnea syndrome.

Study Design

A prospective, experimental animal study.

Setting

Military medical center.

Subjects and Methods

Fifteen fresh porcine tongue specimens were injected with normal saline, and a single coblation probe was applied to the tongue specimens to create multiple submucosal lesions at specific energy settings. Control lesions were created without the use of saline injections. After creating the lesions, the porcine tongue specimens were sectioned and examined grossly. Size and character of lesions were recorded for each of the specimens and were compared across energy settings.

Results

The energy applied at each setting was calculated on the basis of watts multiplied by treatment time. Coblation with saline injection created visible lesions with an average lesion area of 1.20 to 2.87 cm². The average lesion area increased as setting increased. Without saline injection, the average lesion area was 0.15 to 0.8 cm².

Conclusion

The porcine tongue model describes the relationship between lesion size and cold ablation device settings. Setting, but not time, significantly affects lesion size. The coblation setting and treatment time directly impact the amount of energy delivered. Additionally, submucosal normal saline injection significantly increases lesion size at all settings and application times. Given the average lesion diameter described in this study, placing lesions 1 cm apart will optimize the area affected by coblation while minimizing lesion overlap.     

Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management. This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.     

Neoadjuvant therapy may lead to successful surgical resection and improved survival in patients with borderline resectable pancreatic cancer

Background:

Borderline resectable pancreatic cancers are technically amenable to surgical resection, but are associated with increased risk of locoregional recurrence. Patients with these tumours may be treated with neoadjuvant therapy in an attempt to improve margin-negative resection rates.

Methods:

The University of Cincinnati Pancreatic Cancer Database was retrospectively reviewed. Borderline resectable disease was defined by the following radiographic criteria: (i) short segment occlusion of the superior mesenteric vein (SMV), portal vein (PV) or SMV/PV confluence; (ii) short segment hepatic artery encasement, or (iii) superior mesenteric artery/coeliac artery abutment of <180 degrees. Patients with resectable disease who had questionable metastatic disease or poor performance status were also included.

Results:

Twenty-nine patients met the criteria. Of these, 26 underwent a full course of neoadjuvant therapy. Twelve (46%) underwent surgical resection and 14 had tumour progression or were deemed unresectable at laparotomy. The most common neoadjuvant therapy regimen was gemcitabine-based chemotherapy alone (58%). Of those undergoing surgery, 67% had margin-negative (R0) resections and 42% required venous resection. Median survival was 15.5 months for unresected patients and 23.3 months for resected patients.

Discussion:

Borderline resectable pancreatic tumours can be treated neoadjuvantly, resulting in margin-negative resection and survival rates similar to those in initially resectable disease.     

Rapid Intradermal Delivery of Liquid Formulations Using a Hollow Microstructured Array

Purpose

The purpose of this work is to demonstrate rapid intradermal delivery of up to 1.5 mL of formulation using a hollow microneedle delivery device designed for self-application.

Methods

3M??s hollow Microstructured Transdermal System (hMTS) was applied to domestic swine to demonstrate delivery of a variety of formulations including small molecule salts and proteins. Blood samples were collected after delivery and analyzed via HPLC or ELISA to provide a PK profile for the delivered drug. Site evaluations were conducted post delivery to determine skin tolerability.

Results

Up to 1.5 mL of formulation was infused into swine at a max rate of approximately 0.25 mL/min. A red blotch, the size of the hMTS array, was observed immediately after patch removal, but had faded so as to be almost indistinguishable 10 min post-patch removal. One-mL deliveries of commercial formulations of naloxone hydrochloride and human growth hormone and a formulation of equine anti-tetanus toxin were completed in swine. With few notable differences, the resulting PK profiles were similar to those achieved following subcutaneous injection of these formulations.

Conclusions

3M??s hMTS can provide rapid, intradermal delivery of 300?C1,500 µL of liquid formulations of small molecules salts and proteins, compounds not typically compatible with passive transdermal delivery.     

Peer and sexual relationships in the experience of drug-dependent adolescents in a therapeutic community

Introduction and Aims. Evidence for success of adolescent treatment programs, including therapeutic communities, has been found among those who complete treatment. However, there is a lack of research examining peer relationships as part of treatment experience. Given the central role of ‘community’, including peers, as agents of change in therapeutic communities, there is a need to better understand peer relationships in treatment. This ethnographic study provides a window into the dynamics of adolescent relationships in a residential treatment program. Design and Methods. Four months of participant observation, including 21 residents (15 male and 6 female) aged between 14 and 18 years—comprising all residents admitted during the study. All the data in this paper are from those who were 16 years or over. Results. The data reveal the complex peer relationships that form for some residents. Peer groups were found to provide a space for residents to feel included but more often were a mechanism to ostracise or bully others. In contrast to past studies, our study found sexual activity was widespread, in particular among girls. A lack of sex caused frustrations for some and sexual encounters were found to coincide with overt conflict between residents. Conclusions. Treatment programs for adolescents need to more explicitly grapple with the complexity of resident's peer relationships, which may impact on treatment experience. Our study suggests sexual relationships may be common in treatment programs for adolescents and a cause of conflict. Further research about the mediating impact of peer relationships, including sexual relationships, is needed.[Nathan S, Foster M, Ferry M. Peer and sexual relationships in the experience of drug‐dependent adolescents in a therapeutic community. Drug Alcohol Rev 2011;30:419–427]