Partial revision knee arthroplasty with retention of well-fixed components

Retention of well-fixed and well-aligned component is a technically easier option compared to complete revision in a noninfected revision knee arthroplasty. However, it is very often difficult to decide the right treatment in a particular clinical scenario. In this study, we reviewed the available literature with regard to the role and indications of partial revision, advantages and disadvantages of partial revision over full revision and formulate some treatment algorithm based on the available literature. Our review shows that isolate polyethylene insert exchange is more reliable in a well-aligned and well-fixed knees with early evidence of polyethylene synovitis in a knee that was well functioning for at least 10 years. Polyethylene insert exchange is not reliable in the setting of instability or stiffness. Isolated revision of metal-backed patella is possible in elderly low demand patient with well-fixed femoral component and accessible osteolytic lesion. Outcome can be improved by careful patient selection and performing a synovectomy and polyethylene liner exchange at the time of revision. Isolated tibial component revision is a technically difficult procedure and often associated with poor results and hence should be reserved for well-fixed stemmed femoral component with loose tibia in a poor surgical candidate. Isolated femoral component revision is mainly indicated for femoral component malrotation and is technically easy to perform than isolated tibial component revision. None of the authors received support in any form from any source.     

Amphetamine effects in appetitive acquisition depend on the modality of the stimulus rather than its relative validity

Amphetamine has been shown previously to increase the apportioning of associative strength to weak predictors in appetitive Pavlovian conditioning procedures such as latent inhibition and overshadowing. Manipulating the likelihood with which different conditioned stimuli (CSs) predict subsequent delivery of an unconditioned stimulus (UCS) is an alternative method by which the associability of CSs can be influenced. The present experiment tested effects of d-amphetamine (0.5 mg/kg or 1.5 mg/kg administered 15 min prior to conditioning) in appetitive acquisition under partial versus continuous reinforcement of alternative CSs with sucrose pellet UCS delivery. Specifically, male Wistar rats were conditioned to light and tone CSs that were followed by the UCS on 100% or 50% of trials in a cross-over design. It was predicted that amphetamine would disrupt rats' ability to select appropriately the most valid CSs for learning which would be expressed as increased conditioning to weaker, 50% valid CSs. Contrary to prediction, differential responding based on relative validity was preserved under amphetamine, for both light and tone stimuli. Instead, the results showed that responding to light CSs was generally reduced under amphetamine. Conditioning to tone CSs was higher and unaffected by amphetamine. Thus, results demonstrate that amphetamine effects are determined by the properties of the CS used for learning.     

Palatal tremor, focal seizures, repeated miscarriages and elevated anti-thyroid antibodies

Neurological manifestations of thyroid autoimmunity are heterogeneous and nonspecific. The most frequently adopted name for this entity is Hashimoto's encephalopathy although this eponym has been recently contested. In the absence of specific clinical features, diagnosis is suggested by the presence of elevated levels of anti-thyroid antibodies in the appropriate clinical context. We describe a patient with recurrent focal seizures, palatal tremor and elevated anti-thyroid antibodies but no encephalopathy. Her past medical history was marked by recurrent miscarriages. The markedly elevated thyroid antibodies, the temporal relationship between neurological symptoms and hypothyroidism, and the absence of another explanation to her symptoms suggest a causal role of thyroid autoimmunity. In the clinical setting of recurrent spontaneous miscarriages, elevated levels of anti-thyroid antibodies and neurological deficits not attributed to another disease entity, Hashimoto's encephalopathy should be suspected.     

Preoperative observations and short-term outcome after partial external biliary diversion in 13 patients with progressive familial intrahepatic cholestasis

Background

Patients with progressive familial intrahepatic cholestasis (PFIC) often require liver transplantation to survive. An alternative approach is surgical diversion of bile, that is, partial external biliary diversion (PEBD). The aim of the study was to describe 13 patients with PFIC who have undergone PEBD.

Methods

Clinical and laboratory workups including growth data and histology specimens were analyzed to evaluate the short-term effects of PEBD. Follow-up, including liver biopsies, was performed 11 to 21 (median, 14) months post-PEBD.

Results

All patients showed typical features of PFIC. Eight out of 13 presented with variable signs of coagulopathy, and one patient presented with hypocalcemic seizures. The surgery was uneventful in all, but 4 patients were readmitted because of dehydration and electrolyte imbalance caused by excessive stomal losses. One month post-PEBD, 7 patients were apruritic. One patient had stomal dysfunction, showed no improvement on cholestasis after surgery, and had to undergo liver transplantation 2 months post-PEBD. At follow-up, significant biochemical improvement and gains in growth were seen in most of the patients.

Conclusions

Most of the patients with PFIC presented with signs of coagulopathy. Partial external biliary diversion had a dramatic effect on cholestasis and growth, although not all patients benefited from the surgery. Episodes of dehydration post-PEBD must be considered.     

Interventional Management of Renal Bleeding after Partial Nephrectomy

Objective Partial nephrectomy (PN) has emerged as a serious alternative to nephrectomy in oncologic therapy of renal tumours. While complications are rare in general, renal hemorrhage may occur und necessitate angiographic embolization. In this retrospective study, we evaluate the clinical, imagingand procedural findings of seven interventions in five patients with renal hemorrhage after PN. In four out of five patients (80%) the bleeding could be treated successfully by embolotherapy. Conclusion Angiographic embolization in patients with renal hemorrhage after PN is feasible and has a high success rate. The procedure might facilitate avoidance of nephrectomy.     

Adjuvant stereotactic permanent seed breast implant: a boost series in view of partial breast irradiation

PURPOSE: The aim of this study was to use permanent seed implants in the breast and describe our experience with 15 cases, using iodine seed implants as a tumor bed boost. METHODS AND MATERIALS: Breasts were fixed with a thermoplastic sheet, a template bridge applied, the thorax scanned and the images rotated to be perpendicular to the implant axis. Skin, heart, and lung were delineated. A preplan was made, prescribing 50 Gy to the clinical target volume (CTV), consisting in this boost series of nearly a quadrant. Iodine (125) seeds were stereotactically implanted through the template, and results were checked with a postplan computed tomographic (CT) scan. RESULTS: The breast was immobilized reproducibly. Simulation, scanning, and implant were performed without difficulties. Preplan CTV D90% (the dose delivered to 90% of the CTV) was 66 Gy, and postoperative fluoroscopic or CT scan checks were satisfactory. Pre- and postplan dose-volume histogram showed good organ sparing: mean postplan skin, heart, and lung V30 Gy (the organ volume receiving a dose of 30 Gy) of 2 +/- 2.2 mL, 0.24 +/- 0.34 mL, and 3.5 +/- 5 mL, respectively. No short-term toxicity above Grade 1 was noted, except for transient Grade 3 neuropathy in 1 patient. CONCLUSIONS: Seeds remained in the right place, as assessed by fluoroscopy, absence of significant pre- to postplan dose-volume histogram change for critical organs, and total irradiated breast volume. The method could be proposed as a boost when high dosimetric selectivity is required (young patients after cardiotoxic chemotherapy for left-sided cancer). This boost series was a preliminary step before testing partial breast irradiation by permanent seed implant in a prospective trial.     

Comparison of three statistical methods for analysis of fall predictors in people with dementia: Negative binomial regression (NBR), regression tree (RT), and partial least squares regression (PLSR)

Searching for background factors associated with falls in people with dementia is difficult because the population is heterogeneous. The aim of this study was to compare the efficacies of three statistical methods for analysis of fall predictors in people with dementia. NBR, RT and PLSR analyses were compared. Data used for the comparison were from a prospective cohort study of 192 patients at a psychogeriatric ward, specializing in patients with cognitive impairment and related behavioral and psychological symptoms. Seventy-eight of these patients fell a total of 238 times. PLSR and RT analyses are directed at finding patterns among predictor variables related to outcome, whereas an NBR model is directed at finding predictor variables that, independent of other variables, are related to the outcome. The NBR analysis explained an additional 10–15% variation compared with the PLSR and RT analyses. The results of PLSR and RT show a similar plausible pattern of predictor variables. However, none of these techniques appears to be sufficient in itself. In order to gain patterns of explanatory variables, RT would be a good complement to NBR for analysis of fall predictors.     

Routine histologic examination is unnecessary for tonsillectomy or adenoidectomy

OBJECTIVE: To determine whether the current practice and incurred cost of histologic examination of tonsillectomy and adenoidectomy specimens is warranted. STUDY DESIGN: Review article based on medical literature. SUBJECTS AND METHODS: A retrospective PubMed review of all pertinent literature regarding tonsillectomy, adenoidectomy, and related surgical pathology was conducted. References of the articles obtained were reviewed for additional sources. RESULTS: Twenty studies report 54,901 patients and found 54 malignancies (0.087% prevalence). Of these, 48 (88% of the patients) had suspicious features such as tonsillar asymmetry, cervical lymphadenopathy, or abnormal tonsil appearance, preoperatively. The remaining six patients without any suspicious features (better representing true occult malignancy) were 0.011% of the total cases. CONCLUSION: Submission of tonsillectomy, adenoidectomy, or both specimens is warranted only when patients demonstrate findings associated with malignancy: tonsillar asymmetry, history of cancer, neck mass, tonsil firmness or lesion, weight loss, and constitutional symptoms.     

Analgesia after tonsillectomy with controlled intravenous morphine — overdue or exaggerated?

ObjectiveTo assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE).Methods30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities (Numeric Rating Scale – NRS: 0–10) on PODs 1–3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures.ResultsAverage pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects.ConclusionThe PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE.