Quantitative stress radiography of the patella and evaluation of patellar laxity before and after lateral release for recurrent dislocation patella

Purpose

The aims of the present controlled clinical study were to (1) compare patella laxity determined in the outpatient clinic with that in anaesthetized patients and (2) evaluate patella laxity before and after lateral release.

Method

The study evaluated data on 33 knees from 33 patients (average age 19.7 years) between 2007 and 2011. All patients were diagnosed with recurrent dislocation of the patella. Patellar stability was evaluated in each patient thrice: patellas were first imaged in the outpatient clinic prior to surgery at 45° knee flexion with 20 N stress from the medial to lateral side and from the lateral to medial side; then, at the time of surgery, patella stress images were obtained in the same manner before and after the lateral release procedure. Radiological assessments were performed using the medial stress shift ratio (MSSR) and lateral stress shift ratio (LSSR).

Results

There were no significant differences in the LSSR and MSSR before surgery (outpatient data) and in anaesthetized patients before the lateral release procedure. Furthermore, there was no significant difference in MSSR at the time of surgery before and after the lateral release procedure. However, LSSR increased significantly after the lateral release procedure.

Conclusion

The results of the present study suggest that quantitative patella stress radiography in the outpatient clinic is useful when it comes to investigating laxity of the patella, and that lateral release significantly increases lateral, but not medial, laxity in patients with recurrent patellar dislocation.

Level of evidence

IV.     

Pyopneumopericardium caused by perforation of gastric ulcer; report of a case

Pyopneumopericardium caused by transdiaphragmatic perforation of gastric ulcer is very rare. A 60-year-old man was admitted to our hospital because of chest pain with high fever. The chest computed tomography (CT) revealed hydropneumopericardium. The patient was diagnosed as purulent pericarditis. So emergent pericardiectomy and pericardial drainage were performed to relieve cardiac tamponade. Two findings enabled us to diagnose the causation of pyopneumopericardium as gastropericardial fistura. The first finding was that endoscopic examination of upper gastrointestinal tract revealed a deep peptic ulcer in the dome of gastric fundus. The second finding was that a dye solution which was injected into the pericardial cavity via the drainage tube leaked out into the gastric cavity through the ulcer. This patient improved successfully by the treatment of intravenous hyperalimentation including antibiotics and omeprazole. We think that expedient diagnosis and surgical drainage are essential for successful patient outcome.     

Identification of physical and psychosocial problems associated with diabetic nephropathy using the International Classification of Functioning,Disability and Health Core Set for Diabetes Mellitus

Background

We previously demonstrated validation of the Comprehensive International Classification of Functioning, Disability and Health Core Set for Diabetes Mellitus (ICF-CS for DM) in patients with diabetic nephropathy (DMN). The objective of the present study was to identify differences in experience of physical and psychosocial problems between DMN patients with and without hemodialysis (HD), and diabetes patients without nephropathy using the ICF-CS for DM.

Methods

A total of 302 diabetes outpatients (men, 68 %; mean age, 62 years) were interviewed using four components of the ICF-CS for DM including “Body functions”, “Body structures”, “Activities and participation”, and “Environmental factors”.

Results

The mean number of categories in which difficulty was experienced in the four components was significantly greater in DMN patients with HD followed by DMN patients without HD, and diabetes patients without nephropathy (23.9 vs. 18.0 vs. 13.1, respectively). Multivariate logistic regression models revealed that, compared with diabetes patients without nephropathy, diabetes patients with nephropathy were more likely to have difficulty with physical problems and social activities and participation. Among DMN patients, dialysis patients were found to have larger numbers of problems, and face difficulty with employment status after adjusting for sex, age, type, and duration of diabetes.

Conclusion

The results of this study using the ICF-CS for DM identified the areas for improvement among physical and psychosocial problems in DMN patients with and without HD in contrast to diabetes patients without nephropathy.

     

Effect of gravitation for detection of bronchioloalveolar carcinoma on computed tomography

A 64-year-old female was found to have localized ground-glass opacity (GGO) in the middle lobe on a chest computed tomography (CT) for screening. Middle lobectomy with video-assisted thoracoscopic surgery (VATS) was undertaken, and pathological diagnosis was a bronchioloalveolar carcinoma (BAC) in stage IA. A follow-up CT a year following the surgery revealed localized GGO in area S⁶ of the left lung. However, it disappeared during the gravitation-dependent gradient in the observation period. The patient was scanned again under prone position to exclude the gravitational effect, resulting in definite detection of the GGO. Left extended S⁶ segmentectomy with VATS was performed, and pathological diagnosis was a BAC in stage IA. As GGO existing in a gravitation-dependent area may be masked by the gravitation-dependent density, a change of the scanning position may lead to a proper detection of the tumor for the diagnosis of BAC.     

The effects of continuous epidural anesthesia and analgesia on stress response and immune function in patients undergoing radical esophagectomy

We investigated whether perioperative extensive epidural block (C3-L) affects postoperative immune response in patients undergoing radical esophagectomy. Patients undergoing radical esophagectomy were randomly assigned to either general anesthesia with continuous epidural infusion via 2 epidural catheters that was continued for postoperative analgesia (group E, n = 15) or intraoperative general anesthesia and postoperative IV morphine analgesia (group G, n = 15). Plasma levels of stress hormones, cytokines, C-reactive protein (CRP), leukocyte counts, and distribution of lymphocyte subsets were assessed before and after surgery and on postoperative days (PODs) 1 and 3. In comparison with group E, significant increases in plasma epinephrine level at the end of surgery (P < 0.05) and norepinephrine level at the end of surgery (P < 0.01) and on POD1 (P < 0.01) and POD3 (P < 0.01) and significant decrease in cluster of differentiation (CD4/CD8 ratio) at the end of surgery (P < 0.05) were observed in group G. However, there were no significant differences in other variables between groups. In both groups, plasma cortisol, adrenocorticotropic hormone, interleukin (IL)-1beta, IL-6, IL-10, and CRP levels were increased after surgery (each group P < 0.01) and IL-1beta, IL-6, IL-10, and CRP were still increased on POD1 and POD3 (each change, each group P < 0.01). Leukocyte counts were increased on POD1 (each group P < 0.05) and POD3 (each group P < 0.01). The proportion of lymphocytes decreased from the end of surgery to POD3 (each group P < 0.01). The proportion of B cells was increased on POD1 (each group P < 0.01); that of natural killer cells was decreased at POD1 and POD3 (each group P < 0.01). We conclude that tissue damage and inflammation apparently overcome the effects of extensive epidural block on stress response and immune function in radical esophagectomy.     

Bone mineral and other bone components in vertebrae evaluated by QCT and MRI

To evaluate the usefulness of assessing bone components using magnetic resonance imaging (MRI), the contributions of bone components, including mineral, fat and collagen, to bone mineral density (BMD) and T1 relaxation time (T1) were studied using phantoms. Excised human vertebrae were also evaluated by quantitative computed tomography (QCT) and MRI. T1 was shortened with increasing quantities of fat and collagen. In water, T1 was significantly affected by bone density, while in oil, T1 became slightly longer as bone density increased. The presence of fat and collagen caused under- and overestimations of BMD, respectively. There was good correlation between T1 and BMD in osteoporotic vertebrae and the vertebrae with long T1 showed an increased content of hematopoietic marrow and/or abnormally increased bone mineral. It was concluded that the experimental data showed that MRI can contribute to the assessment of bone quality.     

NPHS2 mutations in sporadic steroid-resistant nephrotic syndrome in Japanese children

Podocin is an integral membrane protein encoded by NPHS2, which is mapped to 1q25-31 and is exclusively expressed in glomerular podocytes. NPHS2 mutations are responsible for autosomal recessive familial steroid-resistant nephrotic syndrome (SRNS) with minor glomerular abnormalities or focal segmental glomerulosclerosis (FSGS), which is characterized by early childhood onset (age less than 6 years) and rapid progression to chronic renal insufficiency. This gene mutation is also responsible for an adolescent/adult onset form of autosomal recessive familial FSGS with heavy proteinuria. It has been demonstrated that sporadic SRNS and heavy proteinuria are also due to NPHS2 gene mutations. We isolated genomic DNA from 36 Japanese children with chronic renal insufficiency caused by SRNS or heavy proteinuria, and analyzed all eight exons and exon-intron boundaries of NPHS2 using the polymerase chain reaction and direct sequencing. The age at onset of disease was 3.9+/-0.5 years. There were 29 patients with SRNS and 7 with heavy proteinuria without nephrotic syndrome at the onset, but all patients developed chronic renal insufficiency 4.6+/-0.8 years after the onset. A new homozygous missense variant of NPHS2, G34E (G101A) in exon 1, was detected in 1 of 36 patients. However, this homozygous variant was also found in 1 of 44 normal controls, suggesting that the mutation is a polymorphism. Two silent variants (T954C and A1038G) in exon 8 of this gene were also identified in some of the patients and normal controls, indicating that the silent variants are also polymorphisms. There was no significant difference in the genotypic and allelic frequencies of T954C and A1038G polymorphisms between the patients and normal controls. In conclusion, NPHS2 gene mutations are not a major cause of chronic renal insufficiency caused by sporadic SRNS or heavy proteinuria in Japanese children.     

The impact of repeated subclinical acute rejection on the progression of chronic allograft nephropathy

Chronic allograft nephropathy (CAN) is due to both immunologic and non-immunologic factors and results in the development of nonspecific pathologic features that may even be present in long-term well-functioning renal allografts. To investigate the natural history of CAN and potential risk factors associated with progression of these histologic lesions, this study evaluated the of histologic alterations of 124 sequential protocol biopsies performed at 2, 3, and 5 yr after transplantation in 46 patients who exhibited histologic evidence of CAN in the 1-yr biopsy. The occurrence of late acute rejection (AR) greater than 4 mo posttransplant was significantly associated with the development of histologic CAN. In contrast, early clinical AR occurring within 3 mo had no impact on the subsequent development of CAN at 1 yr. Subclinical AR was evident in association with CAN in 50%, 32%, 19%, and 16% of cases with CAN at 1, 2, 3, and 5 yr, respectively. These acute lesions correlated significantly with histologic progression defined as an increased CADI score of the follow-up biopsies. Furthermore, a group of patients who exhibited repeated subclinical AR in the sequential follow-up biopsies had a lower creatinine clearance at 5 yr after transplantation and worse long-term graft survival. In contrast, the absence of evidence of acute inflammation in association with CAN at any time point was associated with minimal deterioration in renal function or progression of renal lesions during the observation period. These results suggest that the persistence of chronic active inflammation may be responsible for the histologic progression of CAN.