Risk factors for dislocation arthropathy after Latarjet procedure: a long-term study

Purpose

The purpose of this study was to analyse the long-term incidence of dislocation arthropathy after a modified Latarjet procedure for glenohumeral instability.

Methods

Long-term follow-up information was obtained from a consecutive series of patients who had undergone a modified Latarjet procedure by one surgeon between 1986 and 1999. Multivariable regression analysis was performed to examine the relation between the development of a dislocation arthropathy and patients and surgery-related factors.

Results

There were 117 patients (117 shoulders) for evaluation, (35 women and 82 men) with a mean age 28.4 ± 8.5 (range, 16–55). The mean follow-up was 16.2 years (range, ten to 22.2 years). Signs of dislocation arthropathy were found in 36 % of patients, graded as Samilson 1 in 30 %, Samilson 2 in 3 %, and 3 % Samilson 3 in 3 % of patients. Risk factors for dislocation arthropathy included surgery in patients older than 40 years of age (64.3 vs. 34.4 %; adjusted RR 2.2, 95 % CI 1.7–2.9) and lateral positioning of the transferred coracoid process in relation to the glenoid rim (82.4 vs. 30.4 %; adjusted RR 2.3, 95 % CI 1.7–3.2). Patients with hyperlaxity developed less dislocation arthropathy (15 vs. 42.5 %; adjusted RR 0.4, 95 % CI 0.1–0.95).

Conclusion

The development of dislocation arthropathy after the Latarjet procedure remains a source of concern in the long term. It correlates with surgery after the age of 40 and lateral coracoid transfer in relation to the glenoid rim. On the other hand, hyperlaxity seems to have a protective effect on the development of dislocation arthropathy.     

Associations of Frequency and Duration of Patient-Doctor Contact in Hemodialysis Facilities with Mortality

It is unknown whether regular patient-doctor contact (PDC) contributes to better outcomes for patients undergoing hemodialysis. Here, we analyzed the associations between frequency and duration of PDC during hemodialysis treatments with clinical outcomes among 24,498 patients from 778 facilities in the international Dialysis Outcomes and Practice Patterns Study (DOPPS). The typical facility PDC frequency, estimated by facility personnel, was high (more than once per week) for 55% of facilities, intermediate (once per week) for 24%, and low (less than once per week) for 21%. The mean ± SD estimated duration of a typical interaction between patient and physician was 7.7±5.6 minutes. PDC frequency and duration varied across DOPPS phases and countries; the proportion of facilities with high PDC frequency was 17% in the United States and 73% across the other countries. Compared with high PDC frequency, the adjusted hazard ratio (HR) for all-cause mortality was 1.06 (95% confidence interval [CI], 0.96 to 1.17) for intermediate PDC frequency and 1.11 (95% CI, 1.01 to 1.23) for low PDC frequency (P=0.03 for trend). Furthermore, each 5-minutes-shorter duration of PDC was associated with a 5% higher risk for death, on average (HR, 1.05; 95% CI, 1.01 to 1.09), adjusted for PDC frequency and other covariates. Multivariable analyses also suggested modest inverse associations between both PDC frequency and duration with hospitalization but not with kidney transplantation. Taken together, these results suggest that policies supporting more frequent and longer duration of PDC may improve patient outcomes in hemodialysis.Although maintenance hemodialysis (HD) saves lives, survival of patients with ESRD remains poor and is much worse than for the general population.¹ HD facilities differ with respect to provision of important clinical practices;^2,3 among these, differences in patterns of dialysis unit staffing might influence mortality.^4,5 HD patients usually receive thrice-weekly dialysis provided by a multidisciplinary team of health care professionals (doctors, nurses, technicians, dietitians, and social workers). As part of this team, the physician’s role in improving the quality of chronic disease care is considered crucial.^6,7Many health care providers and researchers believe that more frequent and longer patient-doctor contact (PDC) in HD care may improve patient outcomes because it provides physicians with greater opportunity to monitor treatments; enhance communication and build trust with the patient; and detect, prevent, and treat new medical problems.^2,5,8 However, the actual frequency and duration of PDC for HD care have not been reported in many countries, and there is little direct evidence that more frequent and longer PDC contributes to better patient health outcomes. Previous studies from the United States showed that less frequent PDC was associated with lower patient satisfaction, lower patient adherence, lower patient achievement of clinical performance targets, and higher hospitalization, but more frequent PDC was not necessarily related to longer patient survival.^8–10 A recent study based on data from the U.S. Renal Data System (USRDS) also reported no difference in survival for PDC frequency of <4 times per month compared with 4 times per month.¹⁰ However, the study was limited to one country and was unable to evaluate differences in outcomes between 4 times per month and >4 times per month because of limitations of the billing codes and relatively low proportion of high PDC frequency in the United States.This study examined the estimated typical frequency and duration of PDC that occurs at the time of HD treatments and its associations with all-cause mortality as a primary outcome among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS), an international prospective cohort study of HD patients and facilities. PDC was studied at the facility level, reducing the opportunity for patient-level confounding by indication in this international cohort. Among such patients, a high PDC frequency (>4 times per month) is much more common outside of than in the United States. We also examined the associations of PDC frequency and duration with first hospitalization and kidney transplantation as secondary outcomes. A better understanding of the effect of PDC intensity could have implications for health policy in addition to improving health care delivery and HD patient outcomes.     

Parry Romberg Syndrome associated with chronic facial pain

Parry Romberg Syndrome (PRS) is a rare condition of unknown cause and pathophysiology. It is characterized by progressive facial hemiatrophy, and neurological abnormalities are found in 20% of cases. We describe a 50-year-old woman with PRS and severe neurological involvement (lateralised epileptic seizure activity and facial pain refractory to medication). Pain intensity and frequency was reduced and control of epileptic crises was improved using levetiracetam as an additional therapy. In previous published cases associated with facial pain, the most frequent diagnoses were migraine and trigeminal neuralgia. Our findings suggest that in this patient PRS-related persistent pain has peculiar features possibly attributed to the underlying musculoskeletal abnormalities.     

Long-term efficacy of the trans-obturator and retropubic mid-urethral slings for stress urinary incontinence: update from a randomized clinical trial

Purpose

To report the extended long-term results of the use of tension-free vaginal tape(TVT) and trans-obturator tape (TOT) for the treatment of female stress urinary incontinence (SUI).

Methods

A prospective, multicentre randomized clinical trial comparing the use of TVT and TOT was used to evaluate 87 patients. The inclusion criteria were stress or mixed UI associated with urethral hyper mobility (the stress component was clinically predominant), while the exclusion criteria were previous anti-incontinence surgery and/or pelvic organ prolapse. The objective cure criteria were a negative provocative stress test and a negative 1-h pad test, with no further treatment for SUI. The subjective cure criteria were a 3-day voiding diary, quality-of-life questionnaires (UDI6–IIQ7), and patient satisfaction on a scale from 0 to 10.

Results

Eighty-seven patients were evaluated (47 TOT and 40 TVT) at a median follow-up of 100 months. Subjective and objective cure rates were 59.6 and 70.2 % in the TOT group and 75 and 87.5 % in the TVT group. The mid-to-long-term trend was a decreasing continence rate in patients who underwent TOT, compared with a stable rate for TVT. The Kaplan–Meier survival curve showed that continence rate decreased for up to 25 months after surgery, with stabilization thereafter for the TVT group while continuing to drop in the TOT group, with no inter-group difference.

Conclusion

The patients in both groups were highly satisfied at long-term follow-up. The overall continence rate worsened for both groups within 25 months. While the results tend to stabilize in the TVT group, a further decline in the TOT was observed.

     

GABAergic processes in the mesencephalic tegmentum modulate the occurrence of active (rapid eye movement) sleep in guinea pigs

The ventrolateral subdivision of the periaqueductal gray (vlPAG) and the adjacent dorsal mesencephalic reticular formation (dMRF) are involved in the modulation of active (rapid eye movement) sleep (AS). In order to determine the effects on AS of the suppression of neuronal activity in these regions, muscimol, a GABA receptor A (GABA(A)) receptor agonist, and bicuculline, a GABA(A) receptor antagonist, were microinjected bilaterally in guinea pigs and the states of sleep and wakefulness were examined. The main effect of muscimol was an increase in AS; this increase occurred in conjunction with a reduction in the time spent in wakefulness. The powerful effect of muscimol was striking especially when considering the small amount of naturally-occurring AS that is present in this species. Additional observable effects that were induced by muscimol were: 1) long lasting episodes of hypotonia/atonia during wakefulness and quiet sleep that included a lack of extensor tone in the hind limbs, and 2) frequently occurring cortical spindles, similar to those observed during naturally-occurring quiet sleep (sleep spindles), that were present during wakefulness. Conversely, bilateral microinjections of bicuculline induced a prolonged state of wakefulness and blocked the effect of subsequent injections of muscimol. These data suggest that endogenous GABA acts on GABA(A) receptors within the vlPAG and dMRF to promote AS in the guinea pig.     

Effects of repetitive transcranial magnetic stimulation on spike-and-wave discharges

Aim of this study was to evaluate the effect of 5Hz-suprathreshold repetitive transcranial magnetic stimulation (rTMS) on the duration of the spike-and-wave discharges (SWDs) in a patient presenting idiopathic absence seizures. At the moment of the study the patient presented a mild blunting of consciousness due to the high frequency of absences and EEG recordings showed sub-continuous, generalized, symmetrical and synchronous 3c/s SWDs, petit mal status. Trains of 10 stimuli (120% resting motor threshold) were delivered at 5Hz frequency at the beginning of the SWDs. 5Hz-rTMS trains significantly changed the EEG activity by reducing the duration of SWDs without changing the intervals between two consecutive discharges. rTMS had not significant after-effects on the epileptic activity and patient's clinical status. Despite the limitations of a single case report, our neurophysiological findings suggest that 5Hz-suprathreshold rTMS delivered in short trains induces a transitory interference of the ongoing epileptic activity.     

A multiresolution diffused expectation-maximization algorithm for medical image segmentation

In this paper a new method for segmenting medical images is presented, the multiresolution diffused expectation-maximization (MDEM) algorithm. The algorithm operates within a multiscale framework, thus taking advantage of the fact that objects/regions to be segmented usually reside at different scales. At each scale segmentation is carried out via the expectation-maximization algorithm, coupled with anisotropic diffusion on classes, in order to account for the spatial dependencies among pixels. This new approach is validated via experiments on a variety of medical images and its performance is compared with more standard methods.     

Management of Locally Recurrent Retroperitoneal Sarcoma in the Adult: An Updated Consensus Approach from the Transatlantic Australasian Retroperitoneal Sarcoma Working Group

Annals of Surgical Oncology - Surgery is the mainstay of treatment for retroperitoneal sarcoma (RPS), but local recurrence is common. Biologic behavior and recurrence patterns differ significantly...