Factors Predicting the Oculomotor Nerve Palsy following Surgical Clipping of Distal Vertebrobasilar Aneurysms: A Single-Institution Experience

Background The aim of our study was to identify various clinical and radiologic factors that correlate with the oculomotor nerve palsy following clipping of distal vertebrobasilar aneurysms. Methods A total of 48 patients with 51 aneurysms were included in this retrospective study . Patient''s age, gender, size, location, and projection of the aneurysm, preoperative Hunt and Hess (H&H) grade, presence of subarachnoid hemorrhage (SAH), temporary clipping, preoperative third nerve palsy, and Glasgow Outcome Scale were included in the model for analysis. Results A total of 15 patients (31.25%) developed oculomotor nerve palsy following clipping of basilar apex aneurysms. 38 patients (79.2%) presented with SAH and 35 patients (72.9%) had poor H&H grades at presentation. The size of the aneurysm (p = 0.03), preoperative H&H grade (p = 0.04), preoperative oculomotor nerve dysfunction (p = 0.007), and projection of an aneurysm (p = 0.004) had shown a significant correlation with the oculomotor nerve palsy. The size of the aneurysm (p = 0.030, odds ratio: 0.381; 95% confidence interval, 0.175–0.827] was an independent predictor of postoperative nerve dysfunction. Conclusion The size of the aneurysm, clinical grade at presentation, and projection of the aneurysm correlated with the oculomotor nerve dysfunction following clipping. These clinical and radiologic parameters can be used to predict the oculomotor nerve outcome.     

Quantitation of Fetal Heart Function With Tissue Doppler Velocity Imaging—Reference Values for Color Tissue Doppler Velocities and Comparison With Pulsed Wave Tissue Doppler Velocities

Quantitative assessment of fetal heart function has been difficult. Increasingly, tissue Doppler imaging (TDI) is used to measure fetal cardiac function noninvasively. There are two principal techniques, spectral pulsed wave (PW) TDI and color TDI (CTDI). Published reference values for fetal myocardial velocities are based on spectral PW TDI only. However, previous phantom, adult, and animal studies have shown that PW TDI velocities are systematically higher than CTDI velocities. There are no fetal studies so far. We hypothesized that myocardial velocities derived by PW TDI and CTDI are significantly different in the fetus. This prospective observational study included 91 fetuses (gestational age 28.6 ± 6.6 weeks; range 19–40 weeks) seen for routine prenatal ultrasound. From apical 4‐chamber views, tricuspid ring (right ventricle), lateral and septal mitral ring were sampled by PW TDI and CTDI. Bland–Altman analysis was used for comparisons. PW and CTDI S′ velocities correlated strongly in all three cardiac segments (r = 0.6 to 0.9; P < 0.01). There was a systematic bias toward higher velocities with PW TDI versus CTDI (bias 0.96 cm/s; 95% CI 1.08–0.85 cm/s). However, the strength of the correlation and bias varied depending on the region of the fetal heart sampled. PW TDI and CTDI velocity measurements are feasible in the fetus and correlate well. However, PW TDI velocities are higher than CTDI velocities with significant regional variation. This precludes a mathematical conversion of PW to CTDI in vivo. As PW TDI and color TDI vary, different reference values for fetal CTDI velocities were generated.     

Micropapillary bladder cancer: Current treatment patterns and review of the literature

ObjectivesNo guidelines exist for the management of micropapillary bladder cancer (MPBC) and most reports of this variant of urothelial carcinoma are case series comprising small numbers of patients. We sought to determine current practice patterns for MPBC using a survey sent to the Society of Urologic Oncology (SUO) and to present those results in the setting of a comprehensive review of the existing literature.Materials and methodsA survey developed by the Translational Science Working Group of the Bladder Cancer Advocacy Network–sponsored Think Tank meeting was distributed to members of the SUO. The results from 118 respondents were analyzed and presented with a literature review.ResultsMost survey respondents were urologists, with 80% considering bladder cancer their primary area of interest. Although 78% of the respondents reported a dedicated genitourinary pathologist at their institution, there were discrepant opinions on how a pathologic diagnosis of MPBC is determined as well as variability on the proportion of MPBC that is clinically significant. Among them, 78% treat MPBC differently than conventional urothelial carcinoma, with 81% reporting that they would treat cT1 MPBC with upfront radical cystectomy. However, the respondents had split opinions regarding the sensitivity of MPBC to cisplatin-based chemotherapy, which affected utilization of neoadjuvant chemotherapy in muscle-invasive disease.ConclusionsThe management of MPBC is diverse among members of the SUO. Although most favors early cystectomy for cT1 MPBC, there is no consensus on the use of neoadjuvant chemotherapy for muscle-invasive MPBC.     

Cost of Contralateral Prophylactic Mastectomy

Purpose

To compare the healthcare costs of women with unilateral breast cancer who underwent contralateral prophylactic mastectomy (CPM) with those of women who did not.

Methods

We conducted a retrospective study of 904 women treated for stage I–III breast cancer with or without CPM. Women were matched according to age, year at diagnosis, stage, and receipt of chemotherapy. We included healthcare costs starting from the date of surgery to 24 months. We identified whether care was immediate or delayed (CPM within 6 months or 6–24 months after initial surgery, respectively). Costs were converted to approximate Medicare reimbursement values and adjusted for inflation. Multivariable regression analysis was performed to evaluate the effect of CPM on total breast cancer care costs adjusting for patient characteristics and accounting for matched pairs.

Results

The mean difference between the CPM and no-CPM matched groups was $3,573 (standard error [SE] $455) for professional costs, $4,176 (SE $1,724) for technical costs, and $7,749 (SE $2,069) for total costs. For immediate and delayed CPM, the mean difference for total costs was $6,528 (SE $2,243) and $16,744 (SE $5,017), respectively. In multivariable analysis, the CPM group had a statistically significant increase of 16.9 % in mean total costs compared with the no-CPM group (p < 0.0001). Human epidermal growth factor receptor 2/neu-positive status, receipt of radiation, and reconstruction were associated with increases in total costs.

Conclusions

CPM significantly increases short-term healthcare costs for women with unilateral breast cancer. These patient-level cost results can be used for future studies that evaluate the influence of costs of CPM on decision making.     

Intraoperative right coronary artery obstruction due to aortic root prosthesis mismatch after aortic valve replacement—A case report

Iatrogenic intraoperative coronary artery ostial occlusion is quite rare and a dangerous complication of aortic valve replacement. Intraoperative vigilance and prompt intervention are required to manage this fatal complication. A case report of a 48‐year‐old female with normal coronaries who underwent aortic valve replacement and had right ventricle distension is described here. It seemed that the cause which led to right coronary ostial obstruction was due to prosthesis aortic root mismatch and it required bypass with a vein graft. Computed tomographic angiography of aortic root showed abutting of right coronary ostium by the aortic valve prosthesis     

Hip arthroplasty in failed intertrochanteric fractures in elderly

Background:

Failed intertrochanteric fractures in elderly patients are surgical challenge with limited options. Hip arthroplasty is a good salvage procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure.

Materials and Methods:

30 patients of failed intertrochanteric fractures where hip arthroplasty was done between May 2008 and December 2011 were included in study. 13 were males and 17 were females with average age of 67.3 years. There were 2 cemented bipolar arthroplasties, 19 uncemented bipolar, 4 cemented total hip arthroplasty and 5 uncemented total hip arthroplasties. 16 patients had a trochanteric nonunion, which was treated by tension band principles. Total hip was considered where there was acetabular damage due to the penetration of implant.

Results:

The average followup was 20 months (range 6-48 months). Patients were followed up from 6 to 48 months with average followup of 20 months. None of the patients were lost to followup. There was no dislocation. All patients were ambulatory at the final followup.

Conclusion:

A predictable functional outcome can be achieved by hip arthroplasty in elderly patients with failed intertrochanteric fractures. Though technically demanding, properly performed hip arthroplasty can be a good salvage option for this patient group.     

The impact of a corrective tether on a scoliosis porcine model: a detailed 3D analysis with a 20 weeks follow-up

Purpose

Non-fusion treatment for adolescent idiopathic scoliosis generates interest due to the potential for growth preservation and mobility. Using an established porcine scoliotic model, this study aims to evaluate the global alignment and the morphology of the spine with and without application of a non-fusion corrective tether.

Methods

At 12 weeks of age, 21 immature Yorkshire pigs had an induction of scoliosis. Once a 50° Cobb angle was obtained; animals were placed into one of the following groups: a scoliosis model group (SM, n = 11) where animals were euthanized, tether release group (TR, n = 5) where the inducing tether was removed, and an anterior correction group (AC, n = 5) where the inducing tether was removed and non-fusion corrective tether was applied. TR and AC were observed for a further 20 weeks and then euthanized. Post-mortem CT scans were used to create 3D spinal reconstructions to obtain global and morphologic parameters.

Results

Maximal Cobb angle of the scoliotic deformity was significantly lower for AC (27.9° ± 12.0°) than for the two other groups (TR 52.7° ± 10.0°, SM 48.3° ± 7.6°). AC experienced an increase in kyphosis (24.2° ± 15.9°) compared to TR (7.1° ± 6.4°). Correction in the axial plane was also observed in AC versus TR. Correction of vertebral wedging was found for AC compared to SM and TR in the three apical vertebrae.

Conclusions

3D realignment of scoliotic curves was observed with application of the corrective tether. The correction was the product of both mechanical action and growth modulation. These findings are encouraging for future development of a non-fusion device for the treatment of immature scoliotic curves.     

Role of Periarticular Liposomal Bupivacaine Infiltration in Patients Undergoing Total Knee Arthroplasty—A Meta-analysis of Comparative Trials

Background

Over last 2 years, many trials have evaluated newly approved liposomal bupivacaine for periarticular infiltration in total knee arthroplasty (TKA) with mixed results. Our meta-analysis attempts to consolidate the results and make evidence-based conclusions.