Hip pain from impingement and dysplasia in patients aged 20-50 years. Workup and role for reconstruction

In the 20-50-year age group, hip pain usually indicates dysplasia. Chronic mechanical pain is the usual pattern, although acute pain caused by avulsion or degeneration of the labrum may occur. The morphological characteristics of the dysplastic hip should be evaluated, and the link between the dysplasia and the osteoarthritis should be confirmed. Three factors indicate a favorable prognosis: joint space preservation, age younger than 40 years, and correctable femoral and acetabular abnormalities. Reconstruction is highly desirable, as it delays the need for joint replacement by 20 years. After 15 years, good outcomes are seen in 87% of patients after shelf arthroplasty and 85% after femoral varus osteotomy with or without shelf arthroplasty. Chiari acetabular osteotomy can be performed in patients with osteoarthritis but is followed by prolonged limping. Periacetabular osteotomy should be reserved for patients with moderate dysplasia and no evidence of osteoarthritis. Shelf arthroplasty and femoral osteotomy require 5-8 months off work (compared to 5 months after hip replacement surgery) but subsequently permits a far more active lifestyle. Hip replacement, which is required 20 years or more after biologic reconstruction, carries the same prognosis as first-line hip replacement (good results in 80% of patients after 15 years). Acute sharp pain related to anterior hip derangement also occurs in primary femoroacetabular impingement (FAI). The most common pattern is cam impingement, which is due to a decrease in head-neck offset and manifests as pain during flexion and adduction of the hip. Cam impingement can be corrected by anterolateral osteoplasty, which is often performed arthroscopically. Pincer-type impingement is contact between the anterior acetabular rim and the femoral neck due to retroversion of the proximal acetabulum. The imaging study strategy is discussed. Coxometry, computed tomography, and arthrography can be used. Primary FAI, which occurs as a result of geometric abnormalities, should be distinguished from secondary impingement. Causes of secondary impingement include exaggerated lumbar lordosis with pelvic tilt and to hip osteophytosis (sports or posterior hip osteoarthritis). Osteoplasty is rarely appropriate in patients with secondary impingement. The features of acute anterior hip derangement are now better defined. They can be used to guide palliative treatment, which is effective, in the medium term at least. Experience acquired over the last two decades has established the efficacy of surgery for hip dysplasia.     

Superficial venous thrombophlebitis as the initial manifestation of hypereosinophilic syndrome: study of the first 3 cases

BACKGROUND: Superficial venous thrombophlebitis (SVT), often perceived as benign, can coexist with hypercoagulable states. Predisposing risk factors for SVT are similar to those observed for deep venous thrombosis. Association of eosinophilia with SVT is a rare situation that can reveal neoplasia, malignant blood disorders, or vasculitis, but it has never been described in hypereosinophilic syndrome (HES). We herein describe the clinical and biological features, outcome, and response to therapy of 3 patients with SVT associated with eosinophilia that revealed HES. OBSERVATIONS: Superficial venous thrombophlebitis was the initial manifestation of HES in all 3 patients. The mean eosinophil count at diagnosis was 2.4 x 10(3)/muL. All patients received corticosteroids and anticoagulants as the initial treatment, with marked improvement of SVT and return of the eosinophil count to reference limits. All patients experienced relapse and remained dependent on corticosteroid therapy. Two patients received interferon alfa with dramatic regression of SVT, allowing a decrease in the dose of corticosteroids. CONCLUSIONS: We report, to our knowledge, the first 3 cases of SVT related to HES. Superficial venous thrombophlebitis was difficult to treat, with dependence on corticosteroid therapy and partial efficacy of anticoagulant and antiplatelet therapy. Interferon alfa was effective in preventing relapse of SVT related to HES. Mechanisms implied in this thrombogenesis are multiple and remain speculative.     

Peribulbar versus Retrobulbar Anesthesia for Ophthalmic Surgery: An Anatomical Comparison of Extraconal and Intraconal Injections

Background: Peribulbar and retrobulbar anesthesia have long been opposed on the basis of the existence of an intermuscular membrane, which is supposed to separate the intraconal from the extraconal spaces in a water-tight fashion. A local anesthetic injected outside the cone should spread through this septum to reach the nerves to be blocked. The existence of this septum is questioned. The aim of this study was to compare the spread of a colored latex dye injected intraconally or extraconally to simulate both retrobulbar and peribulbar anesthesia.

Methods: The authors used 10 heads from human cadavers. For each head, one eye was injected intraconally, and the other eye was injected extraconally. The heads were then frozen and sectioned into thin slices following various planes. They were then photographed and observed.

Results: There was no evidence of the existence of an intermuscular septum separating the intraconal and extraconal spaces. Those two spaces appeared to be part of a common spreading space, the corpus adiposum of the orbit.     

Physical,Hydric, Thermal and Mechanical Properties of Earth Renders Amended with Dolomitic Lime

The global objective of this work was to manufacture resistant and durable (water resistant) earth renders with good thermal insulation. For this purpose, a medium plastic clayey soil from Kôdéni (Burkina Faso), constituted by kaolinite (62 wt.%), quartz (31 wt.%), and goethite (2 wt.%), was mixed with dolomitic lime (up to 6 wt.%) to manufacture earth renders. The mineralogical, microstructural, and chemical characteristics of dolomitic lime, as well as the physical (linear shrinkage, apparent density, and accessible porosity), hydric (water absorption test by capillarity and spray test), thermal (thermal conductivity), and mechanical (abrasion resistance, flexural, and compressive strengths) properties of the earth renders were evaluated. From these studies, it appears that the addition of dolomitic lime induces the formation of calcium silicate (CSH) and magnesium silicate (MSH) hydrates. These CSH and MSH are mainly formed from the pozzolanic reaction between finely ground quartz and the weak silica of kaolinite in basic media. These formed hydrates improve the physical, hydric, thermal, and mechanical properties of earth renders. This improvement is due to the fact that the formed CSH and MSH stick to the isolated particles of the soil, making them more compact. In view of the good mechanical strength and water resistance, as well as the low thermal conductivity, the elaborated earth renders are suitable for habitats with dry climates, such as the Sahel.     

Impact of β-Lactamase Inhibition on the Activity of Ceftaroline against Mycobacterium tuberculosis and Mycobacterium abscessus

The production of β-lactamases Bla_Mab and BlaC contributes to β-lactam resistance in Mycobacterium abscessus and Mycobacterium tuberculosis, respectively. Ceftaroline was efficiently hydrolyzed by these enzymes. Inhibition of M. tuberculosis BlaC by clavulanate decreased the ceftaroline MIC from ≥256 to 16 to 64 μg/ml, but these values are clinically irrelevant. In contrast, the ceftaroline-avibactam combination should be evaluated against M. abscessus since it inhibited growth at lower and potentially achievable drug concentrations.     

Therapeutic strategy combining intravenous cyclophosphamide followed by oral azathioprine to treat worsening interstitial lung disease associated with systemic sclerosis: a retrospective multicenter open-label study

OBJECTIVE: To evaluate the effects and safety of 6-month intravenous cyclophosphamide (CYC) followed by 18-month oral azathioprine (AZA) therapy in patients with systemic sclerosis (SSc) and worsening interstitial lung disease (ILD). METHODS: All patients presented with ILD and worsened forced vital capacity (FVC) and/or total lung capacity of more than 10% and/or DLCO of more than 15% during the previous year. Treatment was 6 monthly pulses of 0.6 g/m(2) CYC followed by oral AZA for 18 months on disease stabilization or improvement. The endpoint was the rate of percentage change in pulmonary function tests (PFT) after 6 and 24 months. RESULTS: Twenty-seven patients with SSc (20 females) were recruited. Age and disease duration before CYC therapy were (mean +/- SD) 49.4 +/- 15 years and 75.5 +/- 87.8 months, respectively. Mean baseline FVC was 67% +/- 19% of predicted value. At 6 months, in 7 (26%) patients disease was improved, in 12 (44%) stabilized, and in 8 (30%) worsened. Among the 19 (70%) responders, 15 received AZA and 4 declined. Twenty-three completed 2-year followup, 3 died, and one dropped out. Six (22.2%) had improved, 8 (29.6.%) were stable, and 13 (48.2%) had worsened. Evolution of the slope of FVC (in % per year) varied from -15.5 prior to treatment to +3 (p = 0.004) at 6 months and to +1 (p < 5 x 10(-5)) at 24 months. CONCLUSION: Intravenous CYC followed by oral maintenance immunosuppressive therapy for worsening ILD was well tolerated and was associated with stable or improved PFT in 70% and 51.8% of SSc patients at 6 months and 2 years, respectively.     

A phase II study of docetaxel-irinotecan combination in advanced pancreatic cancer

BACKGROUND/AIMS: Chemotherapy provides dismal results in advanced pancreatic cancer patients, even when new compounds, such as gemcitabine, are used. Phase I studies of single-drug therapy with docetaxel or irinotecan suggested a response rate of about 15% in these patients. We report here a phase II study of docetaxel-irinotecan combination in advanced pancreatic cancer patients. METHODOLOGY: Docetaxel 60 mg/m2 was given in combination with irinotecan 250 mg/m2 every 3 weeks. Prednisolone premedication and anti-HT3 drugs were systematically administered. Hematopoietic growth factors were given in case of febrile neutropenia or grade 4 neutropenia at the previous cycle. Endpoints were response rate, progression-free survival, and tolerance. RESULTS: Twenty-seven patients were enrolled, of whom 25 had metastatic disease. We observed 3 partial responses and 11 stabilizations. The median progression-free survival was 4.3 months. Myelosuppression was the main toxicity with 18% of patients experiencing a grade 3-4 event. One patient died of neglected febrile neutropenia. Gastrointestinal toxicity was well controlled. Other toxicities were mild. CONCLUSIONS: This combination has acceptable tolerance and, despite an 11% response rate, some partial responses and prolonged stabilizations were observed. The treatment induced clinical benefit in 33% of the patients. Further trials should focus on docetaxel or irinotecan, possibly used in combination with more conventional strategies (gemcitabine).     

Lactic acidosis as a complication of β-adrenergic aerosols

Lactic acidosis is a marker of tissue hypoperfusion and impairs oxygen delivery. High lactate levels are associated with altered systemic hemodynamics, tissue hypoperfusion, and altered cellular metabolism. Increased lactate levels have also been reported as a complication of β-adrenergic agents administered during asthma therapy. A 49-year-old woman with a prior diagnosis of asthma presented to the emergency department in respiratory distress. She immediately received, in 2 hours, 4 bronchodilator aerosols (ipratropium bromide 0.5 mg/2 mL and terbutaline 5 mg/2 mL) and methylprednisolone intravenous (120 mg). After these 4 aerosols, she was still dyspneic. First, arterial blood gases (pH 7.38; PCO2, 3.92 kPa; HCO3, 19.2 mmol/L) and arterial lactate (lactate, 7.96 mmol/L) were performed with a second series of 4 aerosols. Second, arterial blood gases (pH 7.29; PCO2, 4.01 kPa; HCO3, 15.4 mmol/L) and arterial lactate (lactate, 10.47 mmol/L) were performed at the end of the second series of aerosols. There was no hypoxemia, no inadequate cardiac output state, no anemia, no sepsis, and no use of biguanides. Previous studies have suggested that administration of β agonists can lead to lactic acidemia in the absence of hypoxia or shock, but it is the highest level of lactate that we found in the literature. In sepsis and shock, lactic acidosis is used as a marker of disease severity. In this case, it is not necessarily the sign of an immediate gravity.