Radiographic landmarks for tunnel positioning in double-bundle ACL reconstructions

Purpose  

The purpose of this study was to establish quantitative and qualitative radiographic landmarks for identifying the femoral and tibial attachment sites of the AM and PL bundles of the native ACL and to assess the reproducibility of identification of these landmarks using intraclass correlation coefficients. It was hypothesized that the radiographic positions of the AM and PL bundles could be defined in relation to anatomic landmarks and radiographic reference lines.     

Outcomes of untreated posterolateral knee injuries: an in vivo canine model

Purpose  

The purpose of our study was to determine if sectioning the canine fibular collateral ligament, popliteus tendon, and popliteofibular ligament would result in residual posterolateral instability and produce measureable evidence of early-onset arthritis on ultra-high field MRI.     

Spinal epidural hematoma and high thromboembolic risk: between Scylla and Charybdis

OBJECTIVE: To determine the optimal time for reinstitution of anticoagulant therapy after evacuation of spinal epidural hematoma in patients who have a high risk for cardiogenic embolization. MATERIAL AND METHODS: The clinical histories of all patients with a spinal epidural hematoma encountered at Mayo Clinic Rochester between 1975 and 1996 were reviewed. We present three cases of spontaneous spinal epidural hematoma and the management of anticoagulation in each case. RESULTS: Of the 17 patients identified, 3 received anticoagulant therapy at the onset of the hematoma and were at high risk for cardiogenic embolization. In two patients with a metallic heart valve and one patient with long-standing atrial fibrillation, anticoagulant therapy was discontinued for 5, 13, and 18 days, respectively, after decompressive laminectomy. Systemic embolization occurred in one patient with a previous history of embolization to the femoral artery. No systemic embolization occurred in the two patients with a metallic valve. CONCLUSION: Early resumption of warfarin therapy is indicated after a spinal surgical procedure; however, discontinuation of anticoagulation for several days seems safe while postoperative hemostasis is monitored.     

British HIV Association (BHIVA) national cohort outcomes audit of patients commencing antiretrovirals from naïve

Objectives

The aim of this work was to audit the extent to which routine HIV care in the UK conforms with British HIV Association (BHIVA) guidelines and specifically the proportion of patients starting highly active antiretroviral therapy (HAART) who achieve the outcome of virological suppression below 50 HIV‐1 RNA copies/mL within 6 months.

Methods

A prospective cohort review of adults with HIV infection who started antiretroviral therapy (ART) for the first time between April and September 2006 was carried out using structured questionnaire forms.

Results

A total of 1170 adults from 122 clinical sites participated in the review. Of these patients, 699 (59.7%) started ART at CD4 counts <200 cells/μL and 193 (16.5%) had not been tested for HIV drug resistance. Excluding patients with valid reasons for stopping short‐term ART, 795 (73.5%) of 1081 patients had an undetectable viral load (VL) at follow‐up. Detectable VL was strongly associated with pretreatment CD4 count below 50 cells/μL and pretreatment VL above 100 000 copies/mL, and was not associated with clinic location or case load. About a quarter of patients did not have a VL measurement during the first 6 weeks after starting ART.

Conclusions

The majority of patients who initiated ART at sites participating in this UK national audit were managed within the BHIVA guidelines and achieved virological suppression below 50 copies/mL around 6 months after commencing treatment. Poor VL outcomes were associated with very low CD4 cell count and/or high VL at baseline but not with clinic case load or location. There is an urgent need to diagnose patients at an earlier stage of their HIV disease.     

Clinical importance of cardiac troponin release and cardiac abnormalities in patients with supratentorial cerebral hemorrhages

OBJECTIVE: To determine the Incidence of cardiac troponin T (cTnT) elevation, electrocardiographic (ECG) changes, and arrhythmias in supratentorial intracerebral hemorrhage (ICH) and their association with early mortality. PATIENTS AND METHODS: Patients with supratentorial ICHs admitted to Mayo Clinic, Rochester, Minn, from March 1998 to October 2003 were studied. We excluded moribund patients with ICHs who died within 12 hours of hospital admission. Cardiac troponin T levels measured on admission and day 2 were determined by a third-generation enzyme-linked immunosorbent assay. Continuous ECG monitoring was performed In all patients. Computed tomographic scans were graded and correlated with abnormal cardiac variables. RESULTS: Peak levels of cTnT were elevated at 0.035 to 1.2 microg/L (mean +/- SD, 0.27 +/- 0.38 microg/L) in 10 (20%) of 49 patients and were not associated with changes in creatine kinase MB fraction or ECG results. The cTnT levels did not correlate with location or side of hemorrhage or mortality at 30 days. Seventy (64%) of 110 patients displayed ECG abnormalities. The ECG changes did not correlate with the location or side of ICH, hydrocephalus, midline shift, or extension to the ventricles. CONCLUSION: The cTnT elevations in survivors of acute ICH are frequent but without confirmatory ECG changes that suggest mild myocardial injury. One-month mortality is not influenced by such cTnT elevations. In addition, ECG abnormalities are common but likely benign in patients with supratentorial ICH who survive the initial insult.     

The declaration of death and the withdrawal of care in the neurologic patient

Intensive care technologies have led to an increase in patients who are neurologically devastated and deceased. The practical, moral, and ethical situations encountered can be varied and challenging to manage. Decisions and discussions surrounding withdrawal of care, death by neurologic criteria, and organ donation require significant knowledge of the prognosis, ancillary testing, and definitions of these processes. Experience and skill are often required on the part of physicians and staff to guide families through these most difficult of circumstances.