Totally robotic low anterior resection with total mesorectal excision and splenic flexure mobilization

Some limitations of conventional laparoscopy have been overcome by the enhanced dexterity of the robotic da Vinci system, and its use in gastrointestinal procedures is evolving. However, difficulties accessing multiple quadrants of the abdomen with the first robotic system led to a rather slow introduction of the da Vinci into the field of abdominal surgery compared with its success with urologic and cardiac procedures. The new da Vinci S HD system offers improved range of motion that allows for easier access to a wider surgical field. The authors developed a new “one-step” setup to perform a low anterior resection with total mesorectal excision and splenic flexure mobilization for rectal cancer using a completely robotic approach. This technical report describes all the major aspects for successful performance of this complex minimally invasive procedure.     

Measurements of the quadriceps femoris function after meniscus refixation at the stable athlete’s knee

Introduction  The purpose of this study was to monitor the muscular changes regarding the isokinetic strength and torque pattern of the quadriceps femoris at the stable athlete’s knee after meniscus tear refixation. Materials and methods  Therefore 15 athletes (10 male, 5 female) performing recreational or competitional sports at least five times a week before injury were retrospectively examined in the average 2.5 years after isolated arthroscopic meniscus refixation using Inside Out technique. Next to function and sport activity focused scores the isokinetic peak torque (PT) and in the EMG have been analyzed compared to the uninjured knee. Results  The mean age was 31.26 years. The time between injury and surgery was in the average 13.7 days. According to our first results the data suggest a complete recovery of functional and muscular pattern after meniscus refixation at the stable athlete’s knee. No significant EMG changes for quadriceps femoris were detectable. The PT was fully recovered. The functional and sport activity score analysis (Lysholm and Tegner score) showed no changes in the postoperative long-term follow up compared to the preinjured status. Conclusion  Examining isokinetic PT and the EMG of the quadriceps femoris, these data show no side-to-side differences. Regarding the function and sports activity score system, the functionally high demand patients seem to profit by this procedure.     

Atypical antipsychotic use and risk of fracture in persons with Parkinsonism

Our objective was to estimate the effect of atypical antipsychotics (AAs) on the rate of fractures in a parkinsonism population. We conducted an age‐ and state‐matched nested case‐control study in five states (CA, FL, NY, OH, IL) using the Medicaid analytic extract from 2001 to 2002. Eligible participants had a diagnosis of parkinsonism, excluding persons with secondary parkinsonism, bone cancer, bone infections, schizophrenia, schizoaffective disorder, and those who used conventional antipsychotics. The primary outcome was the occurrence of a fracture of the femur, ankle, fibula, tibia, humerus, radius, or ulna (N = 851). Risk‐set sampling defined controls (N = 4220). We used conditional‐logistic regression to derive adjusted odds ratios (AOR) and 95% confidence intervals of the association between fracture and use of quetiapine, risperidone, or olanzapine in the 60 days before the index date compared to nonuse. After adjustment for confounding, use of quetiapine (AOR 2.4; 95% CI 1.5–3.8), risperidone (AOR 1.2; 95% CI 0.9–1.7), or olanzapine (AOR 1.7; 95% CI 1.2–2.4) was associated with a higher rate of fracture. Use of an AA was associated with a higher rate of fracture in persons with parkinsonism. Prescribers must be cautious when using these agents in elderly persons with parkinsonism. © 2009 Movement Disorder Society     

The relationship between generalized social phobia and avoidant personality disorder in a national mental health survey

Objective: There has been ongoing clinical controversy dating back to the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders concerning the boundaries and extent of overlap between Axis I generalized social phobia (GSP) and Axis II avoidant personality disorder (APD). This study sought to examine the relationship between the fourth edition of Diagnostic and Statistical Manual of Mental Disorders GSP and APD in a large nationally representative sample of the United States population. Method: We used the National Epidemiologic Survey on Alcohol and Related Conditions (n=43,093; age 18+; response rate=81%) to study fourth edition of Diagnostic and Statistical Manual of Mental Disorders Axes I and II psychiatric disorders, assessed by a reliable semi‐structured in‐person interview. Results: The lifetime prevalence was 2.8% for GSP and 2.4% for APD. The overlap between GSP and APD varied according to the number of GSP social situations feared. Although 36.4% of individuals with GSP were diagnosed with APD, the majority (57.3%) of individuals with GSP who feared all 13 social situations assessed were diagnosed with APD. Nearly 40% of individuals with APD also had GSP. Compared to individuals with GSP alone, individuals with comorbid GSP and APD showed significantly lower mental health‐related quality of life on the Medical Outcomes Study Short Form, more interaction and observation fears, and an increased likelihood of having other psychiatric disorders such as major depression. Conclusions: APD and GSP show a high degree of overlap (16–57%), depending on the number of social situations feared. Overall, results suggest that APD and GSP appear to be highly related, but potentially separable constructs. Further research is needed to identify the determinants and consequences of having either or both diagnoses. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

Anatomy,physiology, and pathophysiology of the pedunculopontine nucleus

The pedunculopontine nucleus is composed of cholinergic and non‐cholinergic neurones and is located in the caudal pontomesencephalic tegmentum. Evidence suggests that the nucleus plays a role in the production and control of movement. The nucleus has dense interconnections with the basal ganglia, as well as with other areas of the brain associated with motor control. Electrical stimulation of the pedunculopontine nucleus in the decerebrate cat or rat produces organized locomotor movements. Physiological studies show that the pedunculopontine nucleus modulates its activity in response to locomotion, as well as voluntary arm and eye movements. Degeneration of the pedunculopontine nucleus is seen in post‐mortem brains in humans with Parkinson's disease and Parkinsonian syndromes. In animal models of Parkinson's disease, metabolic changes are seen in the pedunculopontine nucleus, and chemical inhibition or mechanical disruption of the nucleus can produce an akinetic state in animals and man. In this paper we review the literature in support of the suggestion that some of the symptoms of Parkinson's disease are caused by dysfunction of the pedunculopontine nucleus. In accordance with this view, direct stimulation of the nucleus can ameliorate some symptoms of the disease, as demonstrated in both experimental animals and man. © 2008 Movement Disorder Society     

Variability of Gross Tumor Volume Delineation in Head-and-Neck Cancer Using PET/CT Fusion,Part II: The Impact of a Contouring Protocol

The purpose of this study was to assess the efficacy of a gross tumor volume (GTV) contouring protocol on interobserver variability between 4 physicians in positron emission therapy/computed tomography (PET/CT) treatment planning of head-and-neck cancer. A GTV contouring protocol for PET/CT treatment planning was developed utilizing 4 stages: Preliminary contouring on CT alone, determination of appropriate PET windowing, accurate image registration, and modification of CT contouring with correctly formatted PET/CT display and rules for modality disagreement. Two neuroradiologists and 2 radiation oncologists (designated as A, B, C, and D, respectively) were given a tutorial of PET/CT coregistered imaging individualized to their skill level, which included a step-by-step explanation of the protocol with clinical examples. Opportunities for questions and hands-on practice were given. The physicians were asked to re-contour 16 head-and-neck patients from Part I on PET/CT fusion imaging. Differences in volume magnitude were analyzed for statistical significance by analysis of variance (ANOVA) and paired t-tests (α < 0.05). Volume overlap was analyzed for statistical significance using Wilcoxon signed-rank tests (α < 0.05). Volume overlap increased significantly from Part I to Part II (p < 0.05). One previously significant difference between physicians disappeared with the protocol in place. The mean fusion volume of Physician C, however, remained significantly larger than that of Physician D (p < 0.01). This result is unchanged from Part I. The multidisciplinary contouring protocol significantly improved the coincidence of GTVs contoured by multiple physicians. The magnitudes of the volumes showed marginal improvement in consistency. Developing an institutional contouring protocol for PET/CT treatment planning is highly recommended to reduce interobserver variability.     

Outcome in subgroups of mild cognitive impairment (MCI) is highly predictable using a simple algorithm

Although it is well recognized that MCI represents a risk state for subsequent dementia, estimates of conversion vary widely according to the diagnostic criteria employed. There are currently no simple cognitive predictors of high and low risk of progression. We followed 107 non-demented non-depressed subjects from an original cohort of 124—sub-classified as follows: pure amnestic MCI (22), multi-domain MCI (54), non-amnestic MCI (10) and worried well (21). At 2 years, outcome varied considerably. Of the multi-domain MCI group 59% progressed to dementia and only 5% improved. By contrast, in pure amnestic MCI only 18% progressed and 41% improved. Of non-amnestic MCI patients 70% improved. The best predictor of progression was a combination of the Addenbrooke’s cognitive examination (ACE) and the paired associate learning task (PAL), which produced high negative predictive (90%) and sensitivity (94%) values. The results indicate very different outcomes according to whether patients have pure amnestic versus multi-domain MCI. While the latter is an aggressive disorder, the former is more benign and unstable even in a clinic setting. Patients with scores >88 on the ACE and/or <14 errors on the PAL can be confidently reassured of a good prognosis.