Renal allograft tuberculosis: report of three cases and review of literature

Renal transplant recipients are prone to a variety of infections due a persistent immunodepleted state. Incidence of tuberculosis in this population is much higher compared with the general population. While pulmonary tuberculosis still remains the commonest form in this population, renal allograft tuberculosis is very rare. We report two cases of isolated allograft tuberculosis and one case of allograft tuberculosis with coexistent pleuro-pulmonary and bone marrow involvement. All three cases had presented with pyrexia of unknown origin, wherein despite extensive investigations the cause was not found. In two cases the diagnosis was confirmed on histology. Two cases responded to non-rifampicin-based modified antitubercular treatment and one to conventional four-drug Rifampicin-based regimen. Graft function improved in two cases while in one case the graft was lost. Tuberculosis involving the renal allograft is a potential cause for graft dysfunction/loss and requires a high index of suspicion for diagnosis. Timely detection and early institution of therapy can help save the renal allograft.     

A resilience intervention involving mindfulness training for transplant patients and their caregivers

Solid organ and stem cell transplant patients and their caregivers report a substantial level of distress. Mindfulness‐based stress reduction has been shown to alleviate distress associated with transplant, but there is limited experience in this population with other mindfulness‐based interventions, or with combined transplant patient and caregiver interventions. We evaluated a novel, 6‐week mindfulness‐based resilience training (MBRT) class for transplant patients and their caregivers that incorporates mindfulness practice, yoga, and neuroscience of stress and resilience. Thirty‐one heart, liver, kidney/pancreas, and stem cell transplant patients and 18 caregivers at Mayo Clinic in Arizona participated. Measures of stress, resilience, depression, anxiety, health‐related quality of life, positive and negative affect, and sleep were completed at baseline, 6 weeks, and 3 months postintervention. At 6 weeks and 3 months, patients demonstrated significant (P<.005) improvements from baseline in measures of perceived stress, depression, anxiety, and negative affect. Quality‐of‐life mental component (P=.006) and positive affect (P=.02) also improved at follow‐up. Most participants adhered to the program, were satisfied with class length and frequency, and reported improved well‐being as a result of the class. MBRT holds promise as an intervention to enhance resilience and manage stress for transplant patients and their caregivers.     

Brachymetatarsia with accessory navicular in right foot: A rare coincidental finding

A 33 years old female patient presented with posttraumatic pain in the right foot for which radiographs of the right foot was advised. No fracture was detected on radiographs and patient was managed conservatively on medications and posterior splint immobilization. We found coincidentally a short fourth metatarsal and an accessory navicular bone in the right foot radiographs. After 3 weeks of immobilization, she underwent mobilization of the right foot, weight bearing and intensive physiotherapy for 6 weeks. After two months of injury she was still complaining of pain on the plantar aspect of right foot which was diagnosed as metatarsalgia and operated on by excision of the neuroma present in the 3rd web space of the right foot. After surgery she was completely relieved of pain and could do activities well related to the right foot.     

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft

Purpose: Fractures of the humeral shaft are common and account for 3%e5% of all orthopedic injuries. This study aims to estimate the incidence of radial nerve palsy and its outcome when the anterior approach is employed and to analyze the predictive factors. Methods: The study was performed in the department of orthopaedics unit of a tertiary care trauma referral center. Patients who underwent surgery for acute fractures and nonunions of humerus shaft through an anterior approach from January 2007 to December 2012 were included. We retrospectively analyzed medical records, including radiographs and discharge summaries, demographic data, surgical procedures prior to our index surgery, AO fracture type and level of fracture or nonunion, experience of the operating surgeon, time of the day when surgery was performed, and radial nerve palsy with its recovery condition. The level of humerus shaft fracture or nonunion was divided into upper third, middle third and lower third. Irrespective of prior surgeries done elsewhere, the first surgery done in our institute through an anterior approach was considered as the index surgery and subsequent surgical exposures were considered as secondary procedures. Results: Of 85 patients included, 19 had preoperative radial nerve palsy. Eleven (16%) patients developed radial nerve palsy after our index procedure. Surgeons who have two or less than two years of surgical experience were 9.2 times more likely to induce radial nerve palsy (p=0.002). Patients who had surgery between 8 p.m. and 8 a.m. were about 8 times more likely to have palsy (p=0.004). The rest risk factor is AO type A fractures, whose incidence of radial nerve palsy was 1.3 times as compared with type B fractures (p=0.338). For all the 11 patients, one was lost to follow-up and the others recovered within 6 months. Conclusion: Contrary to our expectations, secondary procedures and prior multiple surgeries with failed implants and poor soft tissue were not predictive factors of postoperative deficit. From our study, we also conclude that radial nerve recovery can be reasonably expected in all patients with a postoperative palsy following the anterolateral approach.     

Functional outcome after arthroscopic management of traumatic recurrent dislocation shoulder using Bankart repair and Remplissage techniques

Background

Recurrent dislocation shoulder is one of the common shoulder injuries encountered by the orthopedic surgeon in clinical practice. Bankart repair using the arthroscopic method has become one of the standard techniques in the management of recurrent dislocation shoulder. Remplissage technique can be used as adjunct to Bankart repair in certain conditions.

The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery

Background

Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons.

Transjugular intrahepatic portosystemic shunt for refractory ascites: an analysis of the literature on efficacy, morbidity, and mortality

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is frequently used to treat patients with refractory ascites, but its role is controversial. We sought to determine from the literature the efficacy, morbidity, and mortality associated with TIPS for refractory ascites. METHODS: We searched MEDLINE and identified studies published in English from January, 1985, to March, 2003, that evaluated the effect of TIPS in patients with refractory ascites. Outcomes that were analyzed included complete resolution of ascites, reduction in ascites, mortality, encephalopathy, stenosis, and renal function. Data were analyzed on an intention to treat basis. RESULTS: Of 25 studies identified, 16 were included in the analysis. The pooled estimate for complete response at 6 months was 45% and for any response (complete and partial) was 63%. Pooled 6-month mortality after TIPS was 36%. Risk factors for mortality included renal insufficiency (serum creatinine >1.5 mg/dl), hyperbilirubinemia (total bilirubin >3 mg/dl), advanced age (>60 yr), and poor response to TIPS. The pooled rate of new or worsening encephalopathy after TIPS was 32%. In most cases, encephalopathy was managed medically or by reduction in shunt size; however, refractory cases were associated with 100% mortality in most studies. Studies reporting the effect of TIPS on kidney function showed improvement in creatinine clearance and urinary sodium excretion. CONCLUSIONS: TIPS is effective in eliminating ascites or substantially reducing ascites in cases refractory to medical therapy. Renal insufficiency, refractory encephalopathy, and hyperbilirubinemia were consistently associated with mortality after TIPS. In individuals with risk factors for mortality, alternative strategies should be recommended.     

Does aggressive statin therapy offer improved cholesterol-independent benefits compared to conventional statin treatment?

There is currently intense research interest in the properties of HMG-CoA reductase inhibitors (statins) beyond their well-documented lipid-lowering action. Studies have consistently demonstrated that administration of statin therapy decreases levels of the inflammatory marker C-reactive protein (CRP), a marker associated with an increased risk of cardiovascular events. This effect appears to be independent of the extent of reduction in total or LDL-cholesterol. Statins also appear to improve endothelial dysfunction by increasing endothelium-dependent vasodilatation. There is also evidence that statins inhibit fibrin formation and thrombus development, an effect that which would be clinically beneficial following plaque fissure or rupture. Early preclinical and clinical evidence suggests that there are quantitative differences between statin regimens in terms of their cholesterol-independent properties. Trials comparing equipotent doses of different statins, based on lipid-lowering efficacy, have not reported any differences in cholesterol-independent properties. However, the current evidence base indicates that more aggressive statin regimens are associated with an enhanced anti-inflammatory effect. Intensive lipid-lowering using statin therapy generates a greater reduction in mortality than standard lipid management, and it is possible that enhanced cholesterol-independent effects may account for some of this excess benefit.