Incidence of the Remnant Femoral Attachment of the Ruptured ACL

The presence of remnant tibial and femoral attachments of the ruptured ACL has been described in the literature but the femoral remnant has not been well described as a landmark for tunnel placement during reconstruction. We reviewed operative reports, pictures, and videotapes from 111 ACL reconstructions to determine the incidence of a remnant femoral stump. Patients were divided into two groups: Group A included patients treated from January 2006 through September 2006 (n = 63) when the presence of the femoral footprint was documented retrospectively and Group B included patients treated from September 2006 through June 2007 (n = 48) when the presence or absence of the femoral footprint was documented prospectively. In Group A, there were 48 of 58 (83%) patients with a visible stump and 10 (17%) patients in whom we could not verify the existence of the stump. In Group B, 43 of 44 (98%) patients had a visible stump on the lateral femoral wall that was adequate as a guide for femoral tunnel placement. The native femoral footprint is seen in most cases of ACL reconstruction and can be used for guidance during femoral tunnel preparation.     

Cyclical ischaemic preconditioning modulates the adaptive immune response in human limb ischaemia–reperfusion injury

Background:

Reperfusion injury (RI) has significant local and systemic consequences. Ischaemic preconditioning (IPC) modulates RI and the innate immune response. This study examined whether IPC attenuates RI‐mediated changes in lymphocyte populations and function following elective surgery.

Methods:

Twenty‐five patients sustaining 1 h of tourniquet ischaemia during cruciate ligament reconstruction were randomized before surgery to three 5‐min ischaemia cycles separated by 5 min of reperfusion, or to a control group. Systemic levels of interleukin (IL) 4 and interferon (IFN) γ, and surface expression of CD45ro/ra, CD62L and CD95 were measured. T cells were examined systemically and in stimulated serum co‐culture to determine CD4/CD8 and Th1/Th2 shifts through intracellular cytokine production.

Results:

CD4 CD45ro cell numbers increased after RI without IPC, whereas CD8 cells expressing CD45ro and CD95 increased with IPC. Preconditioned serum in co‐culture attenuated increases in CD4 and decreases in CD8 numbers, a process prevented by inhibition of antigen activation. Following RI, systemic IL‐2 levels were significantly lower after IPC, whereas co‐culture with post‐RI serum increased proinflammatory intracellular cytokine production.

Conclusion:

IPC modulated T cell responses in limb RI through reduced activation and proinflammatory cytokine production by CD4 cells, while preventing CD4/CD8 derangement. IPC prevented lymphocyte‐directed immune dysfunction. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Should Histologic Type be Taken into Account when Considering Neoadjuvant Chemotherapy in Breast Carcinoma?

Abstract:  Neoadjuvant chemotherapy is becoming the standard of care in locally advanced breast cancers. With complete pathologic response, patients may have a better overall survival. However, most patients do not have a complete pathologic response, and it is unclear how this impacts survival and whether histologic subtype or chemotherapeutic histologic changes play a role. We retrospectively identified 49 cases of invasive breast carcinoma treated with neoadjuvant chemotherapy (40 ductal, nine lobular) and examined histologic and biologic features of ductal and lobular carcinoma before and after chemotherapy. Patients with lobular carcinomas presented at a later age and had lower grade tumors that were more likely estrogen and progesterone receptor positive. Ductal carcinomas had a greater frequency of HER-2/neu amplification and increased Ki-67 rate. After chemotherapy, none of the lobular carcinomas had complete pathologic response compared with 28% of the ductal carcinomas (p = 0.01). Lobular carcinomas had more lymph node metastases. At the time of clinical follow-up, no lobular carcinomas had evidence of disease. Only one lobular carcinoma case had any histologic changes after chemotherapy compared with 37–68% of ductal carcinomas (p < 0.05). In ductal carcinomas, higher grade and negative estrogen receptor expression before chemotherapy and presence of foam cell clusters, HER-2/neu expression, and absence of lymphatic or vascular space invasion after chemotherapy correlated with pathologic response (p < 0.05). Decreased Ki-67 rate after chemotherapy correlated with survival (p = 0.024). Breast biomarker status changed in 9% of all lobular carcinomas and 19% of all ductal carcinomas. Lobular carcinomas respond poorly to neoadjuvant chemotherapy as evidence by lack of complete pathologic response and rare histologic tissue response.     

Irreducible Pulled Elbow in an Adolescent. A Case Report

Abstract   We present a case of pulled elbow in an adolescent patient that required open reduction.     

A rare cause of fatal intracranial haemorrhage

Introduction  We report the case of a 53-year-old farmer with a 5-day history of severe headache, photophobia and neck stiffness. Full blood count (platelets 173), coagulation screen were normal throughout. Liver function tests remained normal apart from an elevated gamma-GT (156). CT Brain was normal. CSF analysis showed a WCC of 454/mm³ (60% lymphocytes), elevated CSF protein (1.42 g/l) and a normal CSF glucose. He was commenced on IV antibiotics and IV acyclivor and improved. On day 3 of admission, he complained of a sudden severe headache, became unresponsive (GCS 3/15). Investigations  CT Brain showed a massive left intraventricular haemorrhage. He died 4 days later. Subsequent serum serology for leptospirosis was positive. A repeat sample taken 4 days post-admission, showed a rising IgM indicating active leptospirosis. Detailed pathological examination confirmed intracerebral haemorrhage with normal cerebral vasculature. Conclusion  Leptospirosis is a rare cause of intracerebral haemorrhage even in the absence of coagulopathy.     

Predictors of survival following open and endovascular repair of abdominal aortic aneurysms

Clinical decision making for asymptomatic abdominal aortic aneurysms (AAAs) weighs risk of aneurysm rupture, treatment hazards, and overall survival expectations. AAA diameter is the primary parameter in assessing rupture risk. Perioperative risk assessment has been extensively studied, and in-hospital mortality has been reduced to less than 8% with higher-risk open repair and less than 3% with endovascular repair. The purpose of this report is to determine risk factors that predict 2-year survival following open and endovascular AAA repair. We studied 334 patients enrolled in a multicenter clinical trial evaluating an endovascular graft in comparison to standard open repair of infrarenal AAA. Demographic, medical history, physical examination, laboratory, anatomic, procedural, and standardized risk score system variables were analyzed in a multivariable Cox proportional hazard model. Overall survival was 89% at 2 years. Heart disease, cancer, and stroke were the most common causes of death, and no deaths were due to AAA rupture. Cox modeling demonstrated that there were several independent predictors for death after AAA repair: smaller body mass index (p=0.005), Society for Vascular Surgery pulmonary risk score >or=1 (p=0.005), history of erectile dysfunction (p=0.008), history of heart valve replacement (p=0.008), lower preoperative platelet count (p=0.012), larger ratio of AAA diameter/proximal neck diameter (p=0.020), and lower ankle-brachial index (p=0.031). Age, gender, and open or endovascular treatment group are not significant independent risk factors for 2-year mortality in this study. Clinical, laboratory, and anatomic factors predict survival after open and endovascular repair of AAAs. With progressive reduction of in-hospital mortality, assessment of patient longevity after AAA repair has become a more important factor in clinical decision making. Use of valid predictors of patient survival will optimize resource utilization and improve overall patient outcomes. Better selection of patients for any method of repair may improve overall utility more than choice of open or endovascular techniques.     

Computer‐assisted delivery of cognitive behavioral therapy for anxiety disorders in primary‐care settings

Objectives: This article describes a computer‐assisted cognitive behavioral therapy (CBT) program designed to support the delivery of evidenced‐based CBT for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary‐care settings. The purpose of the current report is to (1) present the structure and format of the computer‐assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients. Methods: Thirteen clinicians using the computer‐assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management study provided Likert‐scale ratings and open‐ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected Results: Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression, and expectations for improvement. Conclusions: Computer‐assisted CBT programs provide a practice‐based system for disseminating evidence‐based mental health treatment in primary‐care settings while maintaining treatment fidelity, even in the hands of novice clinicians. Depression and Anxiety, 2009. Published 2009 Wiley‐Liss, Inc.     

A critical re-appraisal of different ways of selecting ambulatory patients with suspected heart failure for echocardiography

BACKGROUND: ECG and BNP have been assessed as screening tests for LVSD and heart failure. However, echocardiography also provides information about valvular disease and LVH. We assessed how good these screening tests are in identifying whether the subsequent echocardiogram will have any significant abnormality. AIMS: To re-appraise the ECG and BNP as screening tests for echocardiography since there are important practical deficiencies in our current knowledge in this area. METHODS: General practitioners referred suspected heart failure patients for clinical assessment, echocardiography, electrocardiography, and BNP measurement. The accuracy of each screening test and combinations of screening tests were calculated for LVSD, heart failure, valvular disease, and LVH. RESULTS: The sensitivities of the ECG for LVSD, heart failure, LVH and valvular disease were 97%, 95%, 76%, and 69%, respectively. The corresponding figures for BNP were 86%, 82%, 59%, and 48%, respectively. When patients with atrial fibrillation and murmurs were excluded, the values for ECG were 94%, 87%, 53%, and 55%, while for BNP they were 83%, 73%, 50%, and 32%. CONCLUSIONS: ECG interpretation and BNP are adequate screening tests to detect LVSD or heart failure but fail to screen for other echocardiographic abnormalities, like valvular disease and LVH. This remains the case even if patients with atrial fibrillation or heart murmurs are excluded on the basis that they require echocardiography anyway.