A preliminary study on electromyographic analysis of the paraspinal musculature in idiopathic scoliosis

The paraspinal muscles have been implicated as a major causative factor in the progression of idiopathic scoliosis. Therefore, the objectives of this preliminary study were to measure the electromyographic activity (EMG) of the paraspinal muscles to determine its relationship to progression of the scoliotic curve. Idiopathic scoliotic patients were selected and identified afterwards on curve progression. The EMG activity on both sides of the spine was measured in a set of standardized postures using bipolar surface electrodes at the apex and two end vertebrae of the scoliotic curve. An EMG ratio involving measurements of the EMG activity on the convex and concave sides of the scoliotic curve was used to evaluate the paraspinal muscles. Enhanced EMG ratios at the apex of the scoliotic curve were found in both groups during sitting and standing. The most interesting finding was that children with progression of the curve also showed enhanced EMG ratios at the lower end vertebra of the curve. The EMG ratios between the groups were significantly different from each other at the apex and end vertebrae for several test conditions. Overlap in the EMG-ratio ranges made differentiation difficult for prediction of the progression of the individual scoliosis patient. However, the EMG ratio at the lower end vertebra of the scoliotic curve is significantly higher than 1 in all test conditions in the group of children with subsequent progression of the curve, whereas it is always normal in the non-progressive group. Therefore, EMG of the paraspinal muscles might be of value for prediction of progression in idiopathic scoliosis.     

Risk score predicts high‐grade prostate cancer in DNA‐methylation positive,histopathologically negative biopsies

BACKGROUND

Prostate cancer (PCa) diagnosis is challenging because efforts for effective, timely treatment of men with significant cancer typically result in over‐diagnosis and repeat biopsies. The presence or absence of epigenetic aberrations, more specifically DNA‐methylation of GSTP1, RASSF1, and APC in histopathologically negative prostate core biopsies has resulted in an increased negative predictive value (NPV) of ～90% and thus could lead to a reduction of unnecessary repeat biopsies. Here, it is investigated whether, in methylation‐positive men, DNA‐methylation intensities could help to identify those men harboring high‐grade (Gleason score ≥7) PCa, resulting in an improved positive predictive value.

METHODS

Two cohorts, consisting of men with histopathologically negative index biopsies, followed by a positive or negative repeat biopsy, were combined. EpiScore, a methylation intensity algorithm was developed in methylation‐positive men, using area under the curve of the receiver operating characteristic as metric for performance. Next, a risk score was developed combining EpiScore with traditional clinical risk factors to further improve the identification of high‐grade (Gleason Score ≥7) cancer.

RESULTS

Compared to other risk factors, detection of DNA‐methylation in histopathologically negative biopsies was the most significant and important predictor of high‐grade cancer, resulting in a NPV of 96%. In methylation‐positive men, EpiScore was significantly higher for those with high‐grade cancer detected upon repeat biopsy, compared to those with either no or low‐grade cancer. The risk score resulted in further improvement of patient risk stratification and was a significantly better predictor compared to currently used metrics as PSA and the prostate cancer prevention trial (PCPT) risk calculator (RC). A decision curve analysis indicated strong clinical utility for the risk score as decision‐making tool for repeat biopsy.

CONCLUSIONS

Low DNA‐methylation levels in PCa‐negative biopsies led to a NPV of 96% for high‐grade cancer. The risk score, comprising DNA‐methylation intensity and traditional clinical risk factors, improved the identification of men with high‐grade cancer, with a maximum avoidance of unnecessary repeat biopsies. This risk score resulted in better patient risk stratification and significantly outperformed current risk prediction models such as PCPTRC and PSA. The risk score could help to identify patients with histopathologically negative biopsies harboring high‐grade PCa. Prostate 76:1078–1087, 2016. © 2016 The Authors. The Prostate Published by Wiley Periodicals, Inc.     

Bisphosphonates for preventing bone disease in kidney transplant recipients: a meta‐analysis of randomized controlled trials

An estimated 60% of kidney transplant recipients have mineral bone disease and about 0.5% break their hip within the first year after transplantation. We conducted a systematic review of benefits and harms of bisphosphonates in kidney transplant recipients. We searched CENTRAL (Issue 5, 2015) for randomized controlled trials in all languages and screened the reference list of an earlier Cochrane review. One reviewer identified the trials, extracted all data, and assessed risk of bias. Meta‐analysis used a random effects model, with results expressed as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). Bisphosphonates have uncertain effects on death (RR 0.45, CI 0.04–4.69) and vertebral fractures (RR 0.58, CI 0.24–1.43, I² 0%). Bisphosphonates moderately to importantly reduce the loss of vertebral bone mineral density (MD 5.98%, CI 3.77–8.18% change from baseline in g calcium/cm² at 12 months, I² 91%) and femoral bone mineral density (MD 5.57%, 3.12–8.01% change from baseline in g calcium/cm² at 12 months, I² 69%). At this stage, insufficient evidence exists to support routine use of bisphosphonates to reduce fracture risk after kidney transplantation. Data on important health outcomes are lacking, surrogate outcomes poorly reflect bone quality in kidney transplant recipients, and serious adverse events are not studied and reported systematically.     

Reconstruction of the proximal femur with a modular resection prosthesis

Background

Various megaprostheses are currently available for reconstruction of the proximal femur after tumor resection. This study evaluates the survival and complications of a modular megaprosthesis for reconstruction of the proximal femur.

Materials and methods

We studied the medical files of 109 tumor patients (age range 16–86 years) who underwent proximal femoral reconstruction with the MRP^® megaprosthesis from 2002 to 2011. There were 70 patients with metastases, 34 patients with bone sarcomas, and five patients with hematological malignancies; 82 were primary and 27 were revision reconstructions. Mean follow-up was 2.5 years; 31 patients had a minimum five-year follow-up. We evaluated the survival and function of the patients, and the survival and complications of the megaprostheses.

Results

Survival was significantly higher for the patients with bone sarcomas compared to those with metastases and hematological malignancies. Mean MSTS functional score was similar between patients with bone sarcomas and those with hematological malignancies and metastases, and between patients with primary and those with revision reconstructions. Overall survival of the MRP^® megaprostheses was 74 % at 5 and 9 years. Fourteen (13.6 %) major complications occurred at a mean period of 1.4 years (range 3 months to 4.5 years); these included infection (5.8 %), dislocation (3.9 %), local recurrence (2.9 %), and acetabular fracture (1 %).

Conclusion

MRP^® megaprostheses are a valuable reconstruction option after tumor resection of the proximal femur.

     

Effects of salmon calcitonin on trabecular microarchitecture as determined by magnetic resonance imaging: results from the QUEST study.

The unique noninvasive MRI technique was used to assess trabecular microarchitecture at multiple skeletal sites in 91 postmenopausal osteoporotic women receiving nasal spray salmon calcitonin (CT-NS) or placebo over 2 years. In the distal radius and lower trochanter of the hip, individuals treated with CT-NS exhibited significant preservation of trabecular bone microarchitecture compared with placebo, where significant deterioration was shown. MRI analyses of os calcis or microCT/histomorphometric analyses of bone biopsies did not reveal consistent differences in architecture between CT-NS and placebo. INTRODUCTION: It is postulated that the reduction in osteoporotic fracture risk in response to certain antiresorptive osteoporosis therapies is caused less by effects on bone quantity than on bone quality (specifically trabecular microarchitecture). To test this hypothesis, the QUEST study was conducted to assess the effects of nasal spray salmon calcitonin (CT-NS) or placebo on parameters of trabecular microarchitecture at multiple skeletal sites using noninvasive MRI technology and iliac crest bone biopsies by microCT/histomorphometry. MATERIALS AND METHODS: Ninety-one postmenopausal osteoporotic women were followed for 2 years (n = 46 for CT-NS, n = 45 for placebo); all women received 500 mg calcium daily. MRI measurements at distal radius, hip (T2 relaxation time [T2*]), and os calcis (obtained yearly), iliac crest bone biopsies with 2D histomorphometry and 3D microCT (obtained at study onset and conclusion), DXA-BMD at spine/hip/wrist/os calcis (obtained yearly), and markers of bone turnover (obtained at 2-week to 12-month intervals) were analyzed, with an analysis of covariance model used to assess treatment effect for parameters of interest. RESULTS AND CONCLUSIONS: MRI assessment of trabecular microarchitecture at individual regions of the distal radius revealed significant improvement, or preservation (no significant loss), in the CT-NS-treated group compared with significant deterioration in the placebo control group, as reflected in apparent BV/TV (p < 0.03), apparent trabecular number (p < 0.01), and apparent trabecular spacing (p < 0.01). Also, at the hip, the CT-NS group exhibited preservation of trabecular microarchitecture at the lower trochanter (p < 0.05) as determined by T2* MRI technology. Significant deterioration of trabecular bone architecture was noted in the placebo group at the femoral neck, Ward's triangle, and lower trochanteric sites. Apart from a significant increase in apparent trabecular number in the CT-NS group, significant changes within or between groups were not noted at the os calcis. Combined microCT/histomorphometric analysis of iliac crest bone biopsies did not reveal significant differences between treated and placebo groups. In the CT-NS group, regardless of the change in BMD (gain or loss) at the spine, hip, or distal radius, preservation of parameters of trabecular microarchitecture was noted, whereas in the placebo group, regardless of the change in BMD (gain or loss) at the spine, hip, or distal radius, loss or preservation was noted; however, changes in DXA/BMD (of the spine, hip, wrist, os calcis) between CT-NS and placebo groups were not significant. Serum C-telopeptide (S-CTx), a specific bone resorption marker, was reduced by 22.5% at 24 months (p = 0.056). The results of the QUEST study suggest therapeutic benefit of CT-NS compared with placebo in maintaining trabecular microarchitecture at multiple skeletal sites and support the use of MRI technology for assessment of trabecular microarchitecture in clinical research trials. However, the results also highlight site specific differences in response to antiresorptive therapies and the importance of sufficiently large sampling volumes (areas) to obtain reliable assessment of bone architecture.     

Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for volume expansion in cardiac surgery patients: the effects on perioperative bleeding and transfusion needs

In this prospective, randomized, open controlled study we compared the effects on net red blood cell loss of 6% hydroxyethyl starch 130/0.4 (HES: n = 64) and 3% modified fluid gelatin (GEL: n = 68) administered for intravascular volume management in patients undergoing coronary surgery. Blood losses were calculated from determination of circulating blood volume and measurement of preoperative and postoperative hematocrit. Amount of colloids that could be administered was limited to 50 mL/kg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Both groups were similar with regard to demographic and intraoperative variables. Total study drug was 48.9 +/- 17.2 mL/kg in the HES group and 48.9 +/- 14.6 mL/kg in the GEL group. Total red blood cell loss was 544 +/- 305 mL in the HES group and 504 +/- 327 mL the GEL group. Measured blood losses were also similar in both groups (HES, 19.4 +/- 12.3 mL/kg; GEL, 19.2 +/- 14.5 mL/kg). Exposure to allogeneic blood product was comparable in both groups. In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery.     

Update in thoracic epidural anaesthesia

Thoracic epidural analgesia (TEA) provides optimal perioperative anaesthesia and analgesia after thoracic and major abdominal surgery and decreases postoperative morbidity and mortality, mainly by blocking sympathetic nerve fibres. Surgery leads to a stress response characterized by sympathetic arousal, altered balance of catabolic and anabolic hormones, hypermetabolism, negative protein economy, and altered carbohydrate metabolism and immune function. A threefold increase of the plasma level of norepinephrine (noradrenaline) was detected up to 24 hours after surgery. These elevated catecholamine plasma levels are a risk, especially to patients with coronary artery disease, because unlike healthy coronary arteries, the stress response causes a vasoconstriction in arteriosclerotic coronary arteries. TEA results in a vasodilation in stenotic coronary arteries. In patients with instable angina pectoris, TEA reduced the number as well as the duration of episodes of cardiac ischaemia. Furthermore, TEA improves myocardial structure and function after coronary artery bypass grafting. Plasma levels of troponin T and I, as well as of atrial natriuretic peptides, were reduced and echocardiographic parameters of the ventricular wall motion were improved by TEA. Patients showed fewer arrhythmic episodes and postoperative myocardial infarction, and could be extubated earlier. The positive effects of TEA after coronary artery bypass grafting are not limited to a short postoperative period, the 2-year mortality rate also seems to be reduced. Optimized pain control and early mobilization decrease the riskof pulmonary complications, resulting in a shortened stay in intensive care units. In combination with early enteral nutrition, TEA leads to an earlier return of gastrointestinal function. Patients treated with thoracic epidural anaesthesia and analgesia have a better health-related quality of life.     

Arthroscopic meniscus repair in the ACL-deficient knee

Between 1985 and 1995, 45 patients underwent closed meniscus repair. There were 30 men and 15 women with a mean age of 32.5 years. In 23 patients, the anterior cruciate ligament was intact (group 1) whereas it was deficient in 22 patients (group 2). All patients were managed with the same postoperative program of partial weight bearing, immediate motion and rehabilitation of the knee. Five patients had a failed meniscal repair and underwent a repeat arthroscopy and a partial meniscectomy. These patients were considered as failures and excluded from the final scoring. After a mean follow-up of more than 9 years, all patients were subjected to a clinical examination using the Hospital for Special Surgery (HSS) knee rating system. Seven patients in group 2 had episodes of frequent giving way and had their anterior cruciate ligament (ACL) reconstructed 6 and 7 years after the initial meniscus repair. None of the other patients had any clinical symptoms or signs of a meniscal tear. In group 1, 20 patients and in group 2, 14 patients, all had a satisfactory knee score. Even though the failure rate of meniscus repair may be greater in an unstable knee, it is concluded that meniscal repair is not contraindicated in a knee with a deficient ACL.

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Résumé Entre 1985 et 1995 45 malades ont eu une réparation méniscale à foyer fermé. Il y avait 30 hommes et 15 femmes à lâge moyen de 32,5 ans. Chez 23 malades le ligament croisé antérieur (LCA) était intact (Groupe 1), alors quil était défectueux chez 22 malades (Groupe 2). Tous les malades ont eu le même programme postopératoire avec appui partiel, mobilisation immédiate et rééducation du genou. Cinq malades ont présentés un échec et ont subi une arthroscopie secondaire avec méniscectomie partielle. Ces malades ont été considérés comme échecs et ont exclu du dernier marquage de points. Après une moyenne de suivi de plus de neuf ans tous les malades ont été soumis à un examen clinique qui utilise le score HSS pour lestimation du genou. Sept malades du groupe 2 ont eu de fréquent épisodes de dérobement et ont eu leur LCA reconstruit 6 et 7 ans après la réparation du ménisque. Aucun des autres malades navait de symptôme clinique ou de signe dune déchirure méniscale. Vingt malades du groupe 1 et 14 malades du groupe 2 avaient tous un score du genou satisfaisant. Bien que le taux déchec de réparation du ménisque puisse être plus grand dans un genou instable, notre conclusion est que la réparation du ménisque nest pas contre-indiquée sur un genou avec un LCA défectueux.

     

Psychosocial Predictors of Success following Bariatric Surgery

Background: Bariatric surgery is the treatment of choice for morbid obesity, but it does not lead to equal results in every patient. In addition to surgery, a number of non-surgical and psychological factors may influence patients' ability to adjust to the postoperative condition. Understanding the relationship between potential predictive variables and success after bariatric surgery will enable better patient selection, and the development of interventions to improve outcome. Methods: A systematic literature search identified relevant variables, such as demography, preoperative weight, motivation, expectations, eating behavior, psychological functioning, personality, and psychiatric disorders, which may have predictive value for success after bariatric surgery. Results: Greater success following bariatric surgery appears to occur in patients who are young and female, and have a high self-esteem, good mental health, a satisfactory marriage, and high socio-economic status, who are self-critical and cope in a direct and active way, are not too obese, were obese before the age of 18, suffer from and are concerned about their obesity, have realistic expectations and undisturbed eating behaviors. Occasionally, these variables may have poor or no predictive value. Although reliable predictors are lacking, most treatment teams propose their own exclusion criteria. Conclusion: The existing literature about potential predictors of success after bariatric surgery is far from conclusive; it is still uncertain which factors can predict success. Even where psychosocial functioning does not predict outcome, it is important to identify patients' characteristics which may be linked to their prognosis and to provide necessary pre- and postoperative psychosocial interventions.