What next after thermal ablation for varicose veins: Non-thermal ablation?

BackgroundEndothermal treatment of the great saphenous vein has become the first line of treatment for superficial venous reflux. Newer treatments, especially non-thermal ablation have potential benefits both for patient acceptability and decreased risk of nerve injury.ApproachWe describe the current non-thermal options available including advantages and disadvantages. Ultrasound guided foam sclerotherapy avoids the risk of nerve injury, however it is not as effective as endothermal ablation. Mechanochemical endovenous ablation combines mechanical endothelial damage using a rotating wire, with the infusion of a liquid sclerosant (the Clarivein? system). Reports suggest that this system is safe and effective, eliminating the need for tumescent anaesthesia with no reported case of nerve injury. Finally the VenaSeal? Sapheon Closure System comprises the endovenous delivery of cyanoacrylate tissue adhesive to the vein causing fibrosis. Peri-operative discomfort seems to be minimal but the complication of thrombophlebitis has been reported in up to 15% of patients.ConclusionsNon-thermal options promise comparable treatment efficacy without the added morbidity associated with high thermal energies. The potential of treating venous reflux without the risk of nerve damage may change how surgeons approach venous disease.     

Polyarthritis and angioimmunoblastic lymphadenopathy.

Angioimmunoblastic lymphadenopathy (AILD) is a lymphoproliferative disorder with well established clinical and histological features, one of the clinical manifestations being a peripheral polyarthritis. A case of AILD with a symmetrical non-erosive peripheral polyarthritis is described, including the findings in the synovial fluid and histology of the synovium. There was a marked reduction in the number of peripheral blood T lymphocytes bearing the CDT8 phenotype in both the peripheral blood and synovial fluid. The arthritis was difficult to control, requiring large doses of corticosteroids, which produced significant side effects. Levamisole 150 mg, one day each week, was effective in controlling the arthritis and returning the numbers of CDT8 lymphocytes to normal. The aetiology of AILD is unknown, though a defect in T cell regulation, in particular T cell suppression, with a secondary B cell proliferation has been postulated. The demonstration of reduced numbers of lymphocytes bearing the CDT8 phenotype in this patient supports that theory.     

An Immunohistochemical Panel for Reliable Differentiation of Salivary Duct Carcinoma and Mucoepidermoid Carcinoma

Salivary duct carcinoma is a highly aggressive salivary gland malignancy that may be misdiagnosed as high-grade mucoepidermoid carcinoma. We utilized tissue microarrays with 78 examples of mucoepidermoid carcinoma and 47 salivary duct carcinomas to evaluate the utility of an immunohistochemical panel consisting of androgen receptor, Her2/neu, p63, and cytokeratin 5/6 in distinguishing these entities. Among all cases in the cohorts, androgen receptor was highly specific for salivary duct carcinoma, while cytokeratin 5/6 and p63 were specific for mucoepidermoid carcinoma. While the rate of unequivocal Her2/neu overexpression among the salivary duct carcinomas was low (8.9 %), discrimination of salivary duct carcinoma was enhanced when this marker was used in combination with androgen receptor due to profound sensitivity. The immunohistochemical panel was particularly efficacious at distinguishing the problematic subset of high-grade mucoepidermoid carcinomas from salivary duct carcinoma. Utilization of this set of immunohistochemical markers allows reliable differentiation of salivary duct and mucoepidermoid carcinoma, a distinction with important prognostic and therapeutic implications.     

Changes in Sleep Disruption in the Treatment of Co‐Occurring Posttraumatic Stress Disorder and Substance Use Disorders

Sleep disruption appears not only to reflect a symptom of posttraumatic stress disorder (PTSD), but also a unique vulnerability for its development and maintenance. Studies examining the impact of psychosocial treatments for PTSD on sleep symptoms are few and no studies to date of which we are aware have examined this question in samples with co‐occurring substance use disorders. The current study is a secondary analysis of a large clinical trial comparing 2 psychological treatments for co‐occurring PTSD and substance use disorders. Women (N = 353) completed measures of PTSD at baseline, end of treatment, and 3‐, 6‐, and 12‐month follow‐ups. Results indicated that the prevalence of insomnia, but not nightmares, decreased during treatment, and that 63.8% of participants reported at least 1 clinical‐level sleep symptom at the end of treatment. Improvement in sleep symptoms during treatment was associated with better overall PTSD outcomes over time, χ²(1) = 33.81, p < .001. These results extend the existing literature to suggest that residual sleep disruption following PTSD treatment is common in women with co‐occurring PTSD and substance use disorders. Research on the benefits of adding sleep‐specific intervention for those with residual sleep disruption in this population may be a promising future direction.     

Experimental characterisation for micromechanical modelling of CoCr stent fatigue

Fatigue of CoCr alloy stents has become a major concern in recent times, owing to cases of premature fracture, often driven by microstructural phenomena. This work presents the development of a micromechanical framework for fatigue design, based on experimental characterisation of a biomedical grade CoCr alloy, including both microscopy and mechanical testing. Fatigue indicator parameters (FIPs) within the micromechanical framework are calibrated for the prediction of microstructure-sensitive fatigue crack initiation (FCI). A multi-scale CoCr stent model is developed, including a 3D global J₂ continuum stent-artery model and a 2D micromechanical sub-model. Several microstructure realizations for the stent sub-model allow assessment of the effect of crystallographic orientations on stent fatigue crack initiation predictions. Predictions of FCI are compared with traditional Basquin-Goodman total life predictions, revealing more realistic scatter of data for the microstructure-based FIP approach. Comparison of stent predictions with performance of a 316L stent for the same generic design exposes the design as over-conservative for the CoCr alloy. In response, the micromechanical framework is used to modify the stent design for the CoCr alloy, improving design efficiency.     

Big Data and Total Hip Arthroplasty: How Do Large Databases Compare?

Background

Use of large databases for orthopedic research has become extremely popular in recent years. Each database varies in the methods used to capture data and the population it represents. The purpose of this study was to evaluate how these databases differed in reported demographics, comorbidities, and postoperative complications for primary total hip arthroplasty (THA) patients.