Double-bundle anterior cruciate ligament reconstruction in patients aged 60 years and older

Background

This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years.

Methods

Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60-73 years). The mean time from injury to surgery was 80.5 months (range, 1-480 months), and the mean follow-up time was 26.2 months (range, 24-42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren-Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up.

Results

The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2-8 mm) to 0.9 mm (range, 0-2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74-116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren-Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients.

Conclusions

Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years.

Level of evidence

A retrospective study, case series (IV).

Outcomes of pediatric anterior cruciate ligament reconstructions in patients with and without bucket handle meniscus repairs

The purpose of this study was to report the outcomes of concomitant bucket handle meniscal tear (BHMT) repair and anterior cruciate ligament (ACL) reconstruction and to compare the outcomes with those after isolated ACL reconstruction in patients aged ≤16 years. Patients in our database from 2013 to 2017 were retrospectively analyzed. Patients were assigned to one of two treatment groups based on the presence of BHMTs: no meniscal tear group (group A) and BHMT group (group B). All BHMTs were repaired using the combined inside-out with all-inside technique. This study included 64 knees divided into two groups: 47 knees in group A and 17 knees in group B. There was a significant difference in the interval between ACL injury and surgery between groups A and B (69 vs. 150 days, respectively; P < 0.001). Mean postoperative International Knee Documentation Committee and Lysholm scores in group A were slightly, although significantly, improved compared to those in group B (96.5 vs. 92.6, respectively; P < 0.05, and 98 vs. 95, respectively; P < 0.05). There were no significant differences in postoperative anteroposterior laxity and graft failure rate between the groups. In group B, four patients (23.5%) required surgery for incomplete meniscal healing. Postoperative International Knee Documentation Committee and Lysholm scores of patients with BHMTs were significantly lower than those of patients without any meniscal tear, although with significant improvement in the amount of instability. Level of evidence was Level III.

Association Between Knee Alignment and Meniscal Tear in Pediatric Patients with Anterior Cruciate Ligament Injury

BACKGROUND

The present study aimed to evaluate the association between elapsed time from anterior cruciate ligament (ACL) injury to surgical treatment and the incidence of meniscal tears in a cohort of patients ≤16 years old with varus-aligned and non-varus-aligned knees.

METHODS

The study cohort included 123 patients ≤16 years old who underwent primary ACL reconstruction between January 2016 and March 2020. Knee alignment was expressed as the hip-knee-ankle angle (HKAA), as measured preoperatively on an anteroposterior view of 3-dimensional computed tomography of the full length of the lower limb. Varus alignment was defined as an HKAA ≥181.0°, and non-varus alignment was defined as an HKAA <181.0°. Patients were divided into groups according to knee alignment and the elapsed time from injury to surgical treatment: early-treatment group (<60 days) and delayed-treatment group (≥60 days).

RESULTS

A total of 64 varus-aligned and 59 non-varus-aligned knees were identified. Among patients with varus-aligned knees, those in the delayed-treatment group showed a significantly lower rate of lateral meniscal tears (6 of 30, 20%) compared with those in the early-treatment group (17 of 34, 50%; p = 0.015). Among patients with non-varus-aligned knees, there was no significant difference in meniscal tears of any type between the early and delayed-treatment groups. Among patients without medial meniscal injury identified on initial magnetic resonance imaging, those with varus-aligned knees in the delayed-treatment group showed a significantly higher rate of medial meniscal tears at the time of the surgical procedure (8 of 20, 40%) compared with those with non-varus-aligned knees (1 of 18, 6%; p = 0.015).

CONCLUSIONS

Delayed ACL reconstruction in patients ≤16 years old with varus-aligned knees might be associated with an increased incidence of secondary medial meniscal tears. Accordingly, earlier ACL reconstruction in patients with varus-aligned knees should be considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Delayed anterior cruciate ligament reconstruction increases the incidence of medial meniscal bucket handle tears and medial compartment chondral injuries in patients aged 40 years and older

INTRODUCTION

No widely accepted evidence-based indications exist for the initial surgical management of patients with anterior cruciate ligament (ACL) injuries ≥ 40 years old, and treatment for these patients remains controversial. This study aimed to evaluate the association between elapsed time from ACL injury to surgery and the incidence of meniscal tears and chondral injury in patients aged ≥ 40 years.

MATERIALS AND METHODS

The patients who underwent primary ACL reconstruction were divided into two groups based on elapsed time from injury to surgery: early group, < 12 months; and delayed group, ≥ 12 months. Patient records were reviewed for incidence and types of meniscal tears and chondral injuries in each group. Chondral injury grades were evaluated with International Cartilage Regeneration and Joint Preservation Society (ICRS) Criteria.

RESULTS

This study evaluated 67 knees in the early group and 33 knees in the delayed group. Mean ages in each group were 46.9 ± 6.5 and 46.9 ± 6.0. The delayed group showed significantly higher rates of medial meniscal tear [31 of 33, 93.9% vs 29 of 67, 43.3%; P < 0.0001; odds ratio (OR), 20.31; 95% confidence interval (CI), 4.49-91.9], medial femoral condyle chondral injuries ≥ ICRS grade II (15 of 33, 45.5% vs 8 of 67, 11.9%; P < 0.001; OR, 6.15; 95% CI 2.24-16.83), and medial tibial chondral injuries ≥ ICRS grade II (7 of 33, 21.2% vs 3 of 67, 4.5%; P < 0.05; OR, 5.74; 95% CI 1.38-23.9) compared with the early group. With respect to types of medial meniscal tear, the delayed group showed a significantly higher frequency of bucket handle tears (11 of 33, 33.3%) compared with the early group (2 of 67, 3.0%; P < 0.0001; OR, 16.25; 95% CI 3.34-79.1).

CONCLUSIONS

Delayed ACL reconstruction was associated with increased incidence of chondral injuries and medial meniscal tears, particularly bucket handle tears in this cohort.

LEVEL OF EVIDENCE

Level III.

The impact of vitamin D supplementation on body fat mass in elite male collegiate athletes

BACKGROUND

Whether vitamin D supplementation has any effect on body fat percentage, especially among elite athletes, remains unclear. The aim of this study was to evaluate the effect of vitamin D supplementation on serum vitamin D level in elite male collegiate athletes and to analyze its effect on body fat percentage.

METHODS

We enrolled a total of 42 elite male collegiate athletes in this prospective cohort study. In March 2020, body composition monitoring and blood test were performed. All athletes were provided with vitamin D3 supplement tablets of 25 μg/day. The use of the supplement was dependent on athletes' preference. During the study period, their club activities were stopped for 2 months due to the coronavirus disease 2019 outbreak. A second examination, similar to the first one, was performed after approximately 3 months. Supplement usage by each athlete was also confirmed. The participants were divided into a non-supplement group (without supplementation, n = 15) and a supplement group (with supplementation, n = 27).

RESULTS

Regarding baseline data at initial examination, the non-supplement and supplement groups showed significant differences in the mean body fat percentage (9.0% and 12.1%, respectively; P = 0.03) and serum 25(OH)D level (22.7 and 18.5 ng/mL, respectively, P = 0.02). At the time of the second examination, there were no significant differences in the results of both the groups. In terms of mean change value from the first to the second examination, there were significant differences in body fat percentage (1.9 and 0.2%, respectively, P = 0.02) and serum 25(OH)D level (1.7 and 7.2 ng/mL, respectively, P < 0.001) between the two groups. A significant negative correlation was observed between the change ratio of body fat percentage and change value of serum 25(OH)D level (r =  - 0.37, P = 0.02).

CONCLUSIONS

Vitamin D supplementation of 25 μg/day significantly increased the serum 25(OH)D level in elite male collegiate athletes. Vitamin D supplementation may play a role in maintaining athletes' body fat percentage under circumstances where sports activity has decreased.

Development and validation of an iPad-based Japanese language monosyllable speech perception test (iCI2004 monosyllable)

BACKGROUND

Speech perception tests are commonly used as indices reflecting hearing ability in daily life. In Japan, the CI-2004 test, first developed in 2004, is widely used as standard, but it was not validated against a large number of normal hearing controls and hearing loss patients.

AIMS/OBJECTIVES

The primary objective of the present study was to develop and validate iPad-based software for the Japanese monosyllable speech perception test, 'iCI2004'.

MATERIAL AND METHODS

Seven universities and two medical centers participated in this study. The hearing threshold and Japanese monosyllable speech perception test results of 77 people with normal hearing and 459 people with hearing loss were collected.

RESULTS

All participants with normal hearing achieved almost perfect perception results both in quiet and in noise. For cochlear implant users, the average monosyllable speech perception score was 55.1 ± 19.6% in quiet and 40.3 ± 19.2% in noise (SNR + 10dB).

CONCLUSIONS AND SIGNIFICANCE

We developed iPad-based Japanese monosyllable speech perception test software and validated it by testing a large number of controls and hearing loss patients with cochlear implants or hearing aids. The developed monosyllable speech perception test has a sufficiently large dynamic range for assessing improvement in speech perception in Japanese cochlear implant users.

Incidence of Medial and Lateral Meniscal Tears After Delayed Anterior Cruciate Ligament Reconstruction in Pediatric Patients

Background:

The treatment of pediatric anterior cruciate ligament (ACL) injuries is controversial, and no clear management guidelines have been established.

Purpose:

To evaluate the association between elapsed time from ACL injury to surgery and the incidence of meniscal tears and chondral injuries in patients aged ≤16 years.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between December 2012 and April 2019, a total of 207 consecutive knees in 207 patients aged ≤16 years underwent primary ACL reconstruction and were included in this study. Patients were divided into 1 of 2 groups (early group [≤150 days] and delayed group [>150 days]) based on the time between injury and surgery. Patient records, including arthroscopic findings identified by 2 experienced knee surgeons at the time of surgery, were reviewed for demographic information, incidence and types of medial and lateral meniscal tears, and chondral injuries and their locations in each group.

Results:

There were 180 knees in the early group and 27 knees in the delayed group. The delayed group showed a significantly higher rate of medial meniscal tears than the early group: 16 of 27 (59.2%) and 46 of 180 (25.6%), respectively (odds ratio [OR], 4.24 [95% CI, 1.83-9.33]; P = .0011). The delayed group had a significantly lower rate of lateral meniscal tears than the early group: 6 of 27 (22.2%) and 90 of 180 (50.0%), respectively (OR, 0.29 [95% CI, 0.11-0.70]; P = .007). The delayed group had significantly higher rates of chondral injuries in the medial femoral condyle and the medial tibial plateau than the early group: 8 of 27 (29.6%) and 25 of 180 (13.9%), respectively (OR, 2.61 [95% CI, 1.03-6.62]; P = .049), and 2 of 27 (7.4%) and 1 of 180 (0.6%), respectively (OR, 14.32 [95% CI, 1.58-208.10]; P = .045).

Conclusion:

Delayed ACL reconstruction was associated with an increased incidence of medial chondral injuries and medial meniscal tears but with a decreased incidence of lateral meniscal tears.

The factors affecting the timing of bone union after closing-wedge high tibial osteotomy

OBJECTIVE

Closing-wedge high tibial osteotomy (CWHTO) for medial osteoarthritis of the knee is one of the effective osteotomy methods, especially for patients with cartilage damage of the patellofemoral joint, flexion contracture, and requiring a large correction angle.While the bone union at the osteotomy site is finally obtained after CWHTO, there are often differences in the period of the bone union. The purpose of the present study is to investigate the factors affecting the timing of bone union after CWHTO.

METHODS

16 cases of CWHTO were included; they were performed by the same surgeon using precisely the same implants. Among 16 cases in the present study, nobody used low-intensity pulsed ultrasound (LIPUS) within three months after the operation. The patients were divided into two Groups using Plane X-ray and CT within three months after surgery: Group D (8 knees; bone healing was not seen at all) and Group E (8 knees; bone healing was seen).

RESULTS

There were no significant differences in mean age between the two groups, but body mass index (BMI) and bone mineral density (BMD) were significantly higher in Group D (p < 0.05).

CONCLUSION

The present study suggests that BMI and BMD may affect the timing of bone union after CWHTO.

BACKGROUND

Closing-wedge high tibial osteotomy (CWHTO) for medial osteoarthritis of the knee is one of the effective osteotomy methods. The frequency of selecting CWHTO in our hospital in Japan is high, especially for patients with cartilage damage of the patellofemoral joint, flexion contracture, and requiring a large correction angle. On the other hand, while the bone union at the osteotomy site is obtained with both procedures, there are often differences in bone union time for CWHTO compared to Opening-wedge high tibial osteotomy (OWHTO). This difference might affect the early clinical outcome of the operations. We hypothesized that there is some factor to affect bone healing of CWHTO for individual patients.

PURPOSE

To investigate the factors affecting the timing of bone union after CWHTO.

Successful two-stage operation for esophageal necrosis due to proton beam therapy followed by sorafenib in a case of large hepatocellular carcinoma

Background

Locally advanced hepatocellular carcinoma (HCC), which is unsuitable for standard locoregional therapies, remains a challenge to manage. Among the recently developed treatments, proton beam therapy (PBT) has been reported to achieve good local control. However, in patients with large HCC adjacent to the esophagus, high-dose PBT may rarely lead to radiation-induced esophageal necrosis or perforation. Furthermore, the optimal strategy to safely treat these fatal complications remains unclear.

Case presentation

A 49-year-old man who was diagnosed with a large (16 cm) HCC in the right lobe with tumor thrombosis in the main trunk of the portal vein (PVTT) received high-dose hypofractionated PBT in another hospital. A total dose of 66 GyE in 10 fractions was administered to the primary tumor and the PVTT. After 5 months, a 1-cm solitary nodule was noted in the upper lobe of the right lung. Therefore, sorafenib was started. About 6 months after the PBT, lower esophageal mucosal inflammation that progressed to an ulcer was noted. About 7 months after the PBT, the lower esophagus developed full-thickness necrosis. Therefore, emergency thoracoscopic esophagectomy was performed, followed by two-stage reconstruction 2 months later. The operation and postoperative clinical course were mostly uneventful, except for a minor anastomotic leakage. The outcome of the primary HCC, including the PVTT, was graded as a complete response, which has been maintained for 51 months after the PBT.

Conclusion

PBT is a promising option for patients with locally advanced HCC; however, for large tumors adjacent to the esophagus, ischemic esophageal necrosis due to antiangiogenic effects may occur, particularly with the combined use of PBT and sorafenib. In such a life-threatening condition, the thoracoscopic esophagectomy and the two-stage reconstruction are a safe option that can prevent critical postoperative complications due to the poor general condition, effects of PBT on the remnant gastric conduit, and use of sorafenib.

Treatment of open ankle dislocation without associated fractures in a young athlete using external fixation and ligament repair with suture tape augmentation

Background

Ankle dislocation without fracture is an extremely rare injury because it is usually accompanied by concomitant malleolar fractures from the anatomical and mechanical viewpoints.

Case presentation

We report the case of a 17-year-old woman who was injured while playing basketball. Her ankle was swollen and deformed. Plain X-ray revealed tibiotalar dislocation in the medial direction without any fractures.

Immediate reduction and ligament repair using suture tape augmentation were performed.

Conclusions

At 5 months postoperatively, the patient returned to playing basketball without any complaints. After an additional 2 months, the patient participated and played in the Winter Cup 2019 (the national high school basketball tournament in Japan) at the previous performance level.

Recurrent fifth metatarsal stress fractures in a professional soccer player with hypoparathyroidism: a case report

Background

Hypoparathyroidism is characterized by low or inappropriately normal levels of parathyroid hormone leading to hypocalcemia. In this report, a case of recurrent fifth metatarsal stress fractures in a professional soccer player with hypoparathyroidism is presented.

Case presentation

A 23-year-old male professional soccer player developed left foot pain. He had no specific medical or family history. He was diagnosed with a fifth metatarsal stress fracture and underwent osteosynthesis with a cannulated cancellous screw 3 days after the injury. After three and a half months, the X-ray showed bone union, and he returned to full sports activity. However, he felt pain in his left foot again, and a re-fracture was found on X-ray a week later. Osteosynthesis was performed again. Two months after re-operation, the cause of re-fracture was investigated. Laboratory results showed abnormally low levels of serum calcium (8.4 mg/dL) and intact parathyroid hormone (i-PTH: 19.0 pg/mL). However, other laboratory examinations were normal. Therefore, he was diagnosed with primary hypoparathyroidism according to the diagnostic criteria. Medical treatment was started with alfacalcidol 1.0 μg/day. One month after starting medication, the serum calcium improved to 9.4 mg/dL. Four months after the re-operation, the X-ray showed bone union, and he was therefore allowed to play soccer. While he played professional soccer, there were no new subjective complaints.

Conclusions

Hypoparathyroidism may be one of the risk factors for stress fractures. We believe that serum calcium levels should be checked in patients with stress fractures, and if the serum calcium is low, hypoparathyroidism should be considered.

0746 Dynamics of Sleep Stage Transitions in Patients with Narcolepsy and Other Hypersomnias

Introduction

Narcolepsy is a chronic sleep disorder characterized by excessive daytime sleepiness and abnormal REM sleep phenomena. Narcolepsy can be distinguished into type 1 (NT1; with cataplexy) and type 2 (NT2; without cataplexy). It has been reported that sleep stage sequences at sleep-onset as well as sleep-wake dynamics across the night may be useful in the differential diagnosis of hypersomnia. Here we studied dynamic features of sleep stage transitions during whole night sleep in patients with NT1, NT2, and other types of hypersomnia (o-HS).

Methods

Twenty patients with NT1, 14 patients with NT2, and 35 patients with o-HS underwent overnight PSG. Transition probabilities between sleep stages (wake, N1, N2, N3, and REM) and survival curves of continuous runs of each sleep stage were compared between groups. Transition-specific survival curves of continuous runs of each sleep stage, dependent on the subsequent stage of the transition, were also compared.

Results

The probability of transitions from N1-to-wake was significantly greater in NT1 than in NT2 and o-HS while that from N1-to-N2 was significantly smaller in NT1 than in NT2 and o-HS. The probability of transitions from N2-to-REM was significantly smaller in NT1 than in o-HS. Wake and N1 were significantly more continuous in NT1 than in NT2; specifically, N1 followed by N2 was significantly more continuous in NT1 than in NT2 and o-HS. N2 was significantly less continuous in NT1 and NT2 than in o-HS; this was specifically confirmed for N2 followed by N1/wake. REM sleep was significantly less continuous in NT1 than in NT2 and o-HS; specifically, REM sleep followed by wake was significantly less continuous in NT1 than in o-HS. Continuity of N3 did not differ significantly between groups.

Conclusion

Dynamics of sleep stage transitions differed between NT1, NT2, and o-HS. Dynamic features of sleep such as sleep instability, persistency of wake/N1, and REM fragmentation may differentiate NT1 from NT2, while N2 continuity may differentiate narcolepsy from o-HS. The results suggest that sleep transition analysis may be of clinical utility and provide insights into the underlying pathophysiology of hypersomnia and narcolepsy.

Support

JSPS KAKENHI (18K17891 to AK).

Tibial rotational alignment after opening-wedge and closing-wedge high tibial osteotomy

A lot of good outcomes have been reported after opening-wedge high tibial osteotomy (OWHTO) and closing-wedge high tibial osteotomy (CWHTO).The purpose of this study was to examine the rotational alignment after OWHTO and CWHTO performed by the same surgeon in one hospital.

The sample included 30 knees from 24 patients. In all cases, the same orthopaedic surgeon performed the osteotomy surgeries using the same method. The tibial external rotation angle (TERA) was measured using the CT images of proximal tibial plateau and distal tibial malleolus from the consecutive axial CT slices of tibia. In this study, two considerations were examined. The first was the change in rotation angle, which was defined by TERA noted before and after the operation. The second was the relationship between the correction angle of the osteotomy and the rotation angle change of the distal tibia. The first was evaluated using the paired-Student’s t-test, while the second was analyzed with Pearson’s correlation coefficient. In the OWHTO group, the mean TERA was 21.4± 7.0° preoperatively and 20.2 ± 8.0° postoperatively, but no significant difference was seen between pre- and post-operation measurements (p = 0.21). Significant TERA increasing (that is, external rotation of the distal tibia) was seen postoperatively in only three knees. In the CWHTO group, the mean TERA was 19.9 ± 10.5° preoperatively and 16.5 ± 9.5° postoperatively, and significant difference was seen between pre- and post-operative TERA (p < 0.05). No significant correlation was seen between the correction angle and the change of the rotation angle in either group (r = 0.40, r = 0.12) .

In the OWHTO group, both internal and external rotation of the distal tibia can occur after surgery. In the CWHTO group, the distal tibia rotated internally postoperatively. No significant correlation was seen between the correction angle and the change in the rotation angle in either group

Perioperative enteral supplementation with glutamine, fiber, and oligosaccharide reduces early postoperative surgical stress following esophagectomy for esophageal cancer

BACKGROUND

We clarified the effects of perioperative enteral supplementation with glutamine, fiber, and oligosaccharide (GFO) after an esophagectomy on preventing surgical stress.

METHODS

Of 326 patients with esophageal cancer, 189 received GFO administration (GFO group) and 137 did not (control group). The propensity score matching method was used to identify 89 well-balanced pairs of patients to compare postoperative laboratory parameters and clinical and postoperative outcomes.

RESULTS

The duration of the systemic inflammatory response syndrome (SIRS) was significantly shorter in the GFO group compared to the control group (p = 0.002). Moreover, the lymphocyte/neutrophil ratio (L/N ratio) had significantly recovered in the GFO group on postoperative day-3, and the CRP value was significantly lower in the GFO group than that in the control group on postoperative day-2.

CONCLUSIONS

Perioperative use of enteral supplementation with glutamine, fiber, and oligosaccharide likely contributes to a reduction in early surgical stress after an esophagectomy. These beneficial effects can bring about early recovery from postoperative immunosuppressive conditions after radical esophagectomy.

Feeding catheter gastrostomy with the round ligament of the liver prevents mechanical bowel obstruction after esophagectomy

Jejunostomy, which requires the fixation of the jejunum to the abdominal wall, is commonly used as an enteral feeding access after esophagectomy. However, this procedure sometimes causes severe complications, such as mechanical bowel obstruction. In 2009, we developed a modified approach to insert an enteral feeding tube through the reconstructed gastric tube using the round ligament of the liver. The aim of this study is to investigate the usefulness of this approach as compared to the approach through jejunostomy. Between January 2005 and March 2015, 420 patients with thoracic esophageal cancer underwent esophagectomy via thoracotomy and laparotomy. Of these, 214 underwent feeding jejunostomy (FJ group) and 206 patients underwent feeding via gastric tube with round ligament of the liver (FG group). Catheter-related complications, other postoperative complications, and mortality were compared between the two groups. The incidence of catheter site infection during catheterization in the FG group was significantly lower (n = 1/206, 0.5%) compared to the FJ group (n = 11/214, 5.1%) (P < 0.01). The postoperative bowel obstruction did not occur in the FG group, while it occurred in eight patients (3.7%) in the FJ group (P < 0.01). The incidences of other catheter-related and postoperative complications were similar between the two groups. Feeding catheter gastrostomy with the round ligament of the liver can be a useful enteral feeding access after esophagectomy, because the incidence rate of severe catheter-related complications, such as surgical site infection and mechanical obstruction tend to be lower with this technique compare to jejunostomy.

External Carotid Artery Embolization of Dural Arteriovenous Malformations Involving the Cavernous Sinus; Outcome and Role of Venous Thrombosis

Nine patients with dural arteriovenous malformations (AVMs) in the region of the cavernous sinus were treated by means of external carotid artery (ECA) embolization using polyvinyl alcolhol. All AVMs received vascular supply from both the ECA and the internal carotid artery. Seven cases were clinically cured after embolization, while 2 cases with cortical venous drainage and high flow through the shunt were not completely cured. Venous thrombosis was observed in 5 cases before and in 9 after embolization. In 6 cases the drainage pattern changed owing to venous thrombosis. Complete thrombosis of the cavernous sinus was found on a follow-up angiography in 2 cases. Formation of venous thrombosis and occlusion of feeding arteries are crucial factors for success of ECA embolization. Dural AVMs with cortical venous drainage and high flow cannot be relieved by ECA embolization alone owing to difficulty in obtaining thrombosis of the veins.

The Safety of MR Conditional Cochlear Implant at 1.5 Tesla Magnetic Resonance Imaging System

In magnetic resonance imaging (MRI) examination of the patients with the cochlear implant, only limited data have a mention for safety information in the instruction manual supplied by the manufacturers. Therefore, imaging operators require more detailed safety information for implant device. We conducted detailed examination about displacement force, torque, and demagnetizing of the cochlear implant magnet based on American Society for Testing and Materials (ASTM) standard using the PULSAR and CONCERTO (MED-EL) with 1.5 tesla MRI system. As a result, the displacement force and the torque of the implant magnet were less than the numerical values descried in the manual. Therefore, these have almost no effect on the body under the condition described in a manual. In addition, the demagnetizing factor of the cochlear implant magnet occurred by a change magnetic field. The demagnetization depended on the direction of a line of magnetic force of the static magnetic field and the implant magnet. In conclusion, the operator must warn the position of the patients on inducing in the magnet room.

Chylous leakage from a remaining duplicated left-sided thoracic duct after esophagectomy successfully treated by ligation of the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery with the patient in the prone position

A 69-year-old man who had undergone an esophagectomy was diagnosed with chylous leakage on postoperative day 2, and his pleural effusion output gradually increased daily. On postoperative day 6, intranodal lymphangiography using lipiodol demonstrated chylous leakage from branches of an incomplete duplicated left-sided thoracic duct; it also indicated successful ligation of the right-sided thoracic duct at initial operation. After lymphangiography, the chylous leakage did not heal and remained uncontrollable. Based on the preoperative lymphangiographic findings, we ligated the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery, with the patient in the prone position, on postoperative day 9. The patient experienced no other postoperative complications. The use of the prone position with pneumothorax treatment was helpful in providing a wide operative field in the posterior mediastinum, thus allowing for a better chance for a successful postoperative outcome.

Usefulness of Ultrasonography for Diagnosis of Small Bowel Tumors: A Comparison Between Ultrasonography and Endoscopic Modalities

Ultrasonography is a standard, noninvasive modality used to evaluate patients with gastrointestinal diseases. This study assessed the usefulness of ultrasonography in the detection of small bowel tumors. This study enrolled 558 consecutive patients (295 males, 263 females; mean age 71.1 years) who underwent ultrasonography before capsule endoscopy and/or balloon-assisted endoscopy. Ultrasonographic detection of small bowel tumors was compared with detection by capsule endoscopy and/or balloon-assisted endoscopy. In addition, factors affecting small bowel tumor detection by ultrasonography and clinical characteristics of patients with small bowel tumors undetected by ultrasonography were evaluated. Ninety-seven tumors (52 benign, 45 malignant) detected by capsule endoscopy and/or balloon-assisted endoscopy were retrospectively analyzed. The sensitivity and specificity of ultrasonography in the detection of small bowel tumors were 50.5% (47/93) and 100% (465/465), respectively. If we restricted patients to those with a tumor >20 mm in size, its detection ratio would become higher (91.7%): the ratio of submucosal tumor >20 mm in size was 85.7% (6/7) and that of partial and circumferential ulcerative tumors >20 mm in size was 96.9% (31/32), respectively. Small bowel tumors detected by ultrasonography (mean 33.2 mm) were significantly larger than those undetected by ultrasonography (mean 8.7 mm). The percentage of small bowel tumors located in the ileum detected by ultrasonography (70.6%) was significantly higher than those undetected by ultrasonography (29.4%). Of the 46 small bowel tumors undetected by ultrasonography, 42 (91.3%) were benign tumors with good clinical prognosis. Ultrasonography is a useful modality for detecting larger small bowel tumors and ulcerative lesions. Ultrasonography should be considered a first-line modality for patients suspected of having small bowel tumors, because most small bowel tumors undetected by ultrasonography were benign tumors with good clinical prognosis.

Impact of docetaxel in addition to cisplatin and fluorouracil as neoadjuvant treatment for resectable stage III or T3 esophageal cancer: a propensity score-matched analysis

PURPOSE

To investigate the influence of addition of docetaxel to neoadjuvant chemotherapy (NAC) with cisplatin plus 5-fluorouracil (CF) in patients with clinical stage III or T3 esophageal squamous cell carcinoma.

METHODS

Information about 209 esophageal cancer patients with stage III or T3 disease, who underwent NAC consisting of CF with or without docetaxel, was reviewed. The survival outcomes were analyzed using the Kaplan-Meier method and propensity score-adjusted Cox proportional hazards models. The relevant variables were included in the propensity score model.

RESULTS

NAC was administered to 149 patients in the CF group and 60 patients in the docetaxel plus CF (DCF) group. Overall, 129 patients treated with CF and 58 patients treated with DCF underwent surgery after NAC. The overall response rate was significantly higher in the DCF group compared with the CF group (61.0 vs. 43.2 %, p = 0.021). After matching, recurrence-free survival did not differ statistically between the CF and DCF groups [hazard ratio (HR) 0.83, 95 % confidence interval (CI) 0.50-1.37, p = 0.46]. After matching, the improvement in overall survival in the DCF group reached statistical significance (HR 0.49, 95 % CI 0.24-0.999, p = 0.050). No significant differences in rate of locoregional or distant recurrences were observed between the CF and DCF groups (53.0 vs. 48.3 %, p = 0.54).

CONCLUSIONS

NAC with DCF is superior to CF in patients with clinical stage III or T3 esophageal squamous cell carcinoma.

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: a case report and literature review

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Cytokines induce MMP-3-regulated proliferation of embryonic stem cell-derived odontoblast-like cells

OBJECTIVES

Matrix metalloproteinase (MMP)-3 expression increases after pulpectomy and accelerates angiogenesis in rat dental pulp by an uncharacterised mechanism. Odontoblasts, a major component of dental pulp, could represent a therapeutic target. We investigated whether MMP-3 activity is induced by cytokines and/or is associated with cell proliferation and apoptosis in embryonic stem cell-derived odontoblast-like cells.

MATERIALS AND METHODS

We used reverse transcriptase polymerase chain reaction, western blotting, an MMP-3 activity assay, a BrdU-cell proliferation enzyme-linked immunosorbent assay and DNA fragmentation analysis to evaluate siRNA-mediated downregulation of MMP-3 expression and activity, and any changes in the proliferative and apoptotic responses associated with this reduced expression.

RESULTS

Pro-inflammatory cytokines (interleukin-1β, tumour necrosis factor-α and interferon-γ, at relatively low concentrations) induced MMP-3 mRNA and protein expression, and increased MMP-3 activity and cell proliferation, but not apoptosis. MMP-3 silencing produced a potent and significant suppression of cytokine-induced MMP-3 expression and activity, decreased cell proliferation and increased apoptosis. These effects were rescued by application of exogenous MMP-3.

CONCLUSIONS

Our results suggest that pro-inflammatory cytokines induce MMP-3-regulated cell proliferation and anti-apoptosis effects in odontoblast-like cells derived from embryonic stem cells, in addition to their well-documented destructive role in inflammation.

Implications for the American Joint Committee on Cancer staging systems on esophageal squamous cell cancer patients receiving multimodality therapy

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Background: The 7th edition of the American Joint Committee on Cancer (AJCC) staging system is based on pathologic data from esophageal cancers treated by surgery alone. The objective of this study was to evaluate the prognostic impact of the pretreatment clinical stage (cTNM) and posttreatment pathologic stage (ypTNM) on esophageal cancer patients undergoing neoadjuvant chemotherapy followed by surgery (NAC-S). Methods: Information on 245 consecutive esophageal squamous cell carcinoma patients undergoing NAC-S was reviewed. Data collected included demographics, cTNM, ypTNM, and survival. Statistical methods included the Cox regression model, Akaike information criterion (AIC) within the Cox proportional hazard regression model, and Kaplan-Meier analyses. Results: The overall three-year survival rate was 67.6%. There were significant differences between stages II and III in cTNM and ypTNM stage, respectively (P < 0.01, respectively). There were no significant survival differences between stages I and II, between stages III and IV in each TNM stage. For all patients, cN stage (cN0 vs. cN1-3), ypT stage (ypT0-2 vs. ypT3-4), ypN stage (N0 vs. N1-3), and ypM stage were independent prognostic factors by multivariate analysis (P< 0.05). Compared with cTNM stage, ypTNM stage has a smaller AIC value, which described the optimum prognostic stratification. Conclusions: Our study indicates that the ypTNM stage of the 7th edition of AJCC staging system has better performance than the cTNM stage in patients undergoing NAC-S.

True left-sided gallbladder with a portal anomaly: report of a case

A 65-year-old female who presented with back pain was diagnosed to have the presence of biliary sludge in the gallbladder. Computed tomography showed that the round ligament connected to the left portal umbilical portion was in the normal anatomical position. However, the gallbladder was located to the left of the middle hepatic vein and the round ligament, attached to the left lateral segment of the liver. The right posterior portal vein diverged alone from the main portal vein, and there was a long stem from the right anterior and left portal veins. Laparoscopic cholecystectomy confirmed the abnormal location of the gallbladder. Most reported cases of left-sided gallbladder are caused by a right-sided round ligament, which is called a "false" left-sided gallbladder. A case of left-sided gallbladder with a normal left-sided round ligament, which is designated as a case of "true" left-sided gallbladder, is extremely rare.

Effective stochastic resonance of coupled excitable elements under noise of unequal amplitude

Effective stochastic resonance (SR) is numerically studied using a model of two coupled excitable FitzHugh-Nagumo elements exposed to noise of unequal amplitude. Compared to previous SR models of a single excitable element and of two coupled excitable elements exposed to noise of equal amplitude, the present model exhibits a more intense resonance to the external signal. To extract the key dynamics of this effective SR, the idea of triggered excitation is introduced. Triggered excitation means a process in which the noise-free element is excited synchronously to the external signal with the triggering action of another element that randomly fluctuates asynchronously to the external signal. A deterministic simulation simply proving the triggered excitation process supports our idea.

High-density lipoprotein cholesterol is positively associated with hypertension in apparently healthy Japanese men and women

Among five components of metabolic syndrome, high-density lipoprotein (HDL) cholesterol is unique because it is not significantly associated with blood pressure. This study looks at cross-sectional relationships between HDL cholesterol and hypertension using medical check-up data from 1803 apparently healthy Japanese men aged 49.9 +/- 9.0 years, and 1150 Japanese women aged 49.5 +/- 9.0 years. Pearson's correlation coefficients between systolic blood pressure (SBP)/diastolic blood pressure (DBP) and HDL cholesterol were -0.01 (ns)/-0.01 (ns) in men and -0.04 (ns)/-0.01 (ns) in women. The standardised partial regression coefficient of HDL cholesterol for SBP/DBP (mmHg) controlling for age, body mass index (BMI), fasting plasma glucose (FPG), triglycerides, high-sensitivity C-reactive protein (hs-CRP) and low-density lipoprotein (LDL) cholesterol were 0.15 (P < 0.0001)/0.15 (P < 0.0001) in men and 0.10 (P < 0.0001)/0.12 (P < 0.0001) in women. The odds ratio (OR; 95% confidence interval [CI]) of a 1 mg/dL increment of HDL cholesterol for hypertension controlling for age, BMI, FPG, triglycerides, hs-CRP, LDL cholesterol, metabolic syndrome, diabetes, exercise status, drinking status, and smoking status was 1.03 (1.02-1.04; P < 0.001) in men and 1.03 (1.01-1.05; P = 0.002) in women. Thus, HDL cholesterol was independently positively associated with hypertension in apparently healthy Japanese men and women.

Effective stochastic resonance under noise of heterogeneous amplitude

Stochastic resonance is numerically and analytically studied using a model wherein two coupled particles are exposed to noise of heterogeneous (i.e., particle-dependent) amplitude. In a certain range of coupling constant and under noise of heterogeneous amplitude, a particle is observed to resonate intensively to the external field. In other words, one particle under noise of very small or zero amplitude exhibits intensive resonance with the assistance of a highly fluctuating second particle under noise of large amplitude. This intensive resonance is interpreted as a product of the unique combinatory dynamics between one particle that stochastically fluctuates and another particle that classically resonates to the external field.

Comparative pharmacokinetics of RAD001 (everolimus) in normal and tumor-bearing rodents

PURPOSE

Comparative pharmacokinetic (PK) analysis of the mTOR inhibitor RAD001 (everolimus) in rats and mice.

METHODS

Blood cell partitioning, plasma protein binding and PK parameters of RAD001 in blood and tissues (including brain) of both mice and rats were determined. PK modeling predicted plasma/blood and tumor levels from a variety of regimens and these were compared with the known human PK profile. DCE-MRI was used to compare tumor vascularity between mice and rats. Estimation of IC50 values in vitro and ED50 values in vivo were used to provide an indication of anti-tumor activity.

RESULTS

The PK properties of RAD001 differed between mice and rats, including erythrocyte partitioning, plasma protein binding, plasma/blood t(1/2), oral bioavailability, volume of distribution, tissue/tumor penetration and elimination. Modeling of tumor and blood/plasma PK suggested that in mice, multiple daily administrations result in a 2-fold increase in tumor levels of RAD001 at steady state, whereas in rats, a 7.9-fold increase would occur. Weekly high-dose regimens were predicted not to facilitate tumor accumulation in either species. Total tumor levels of RAD001 were four- to eight-fold greater in rats than in mice. Rat tumors had a >2-fold greater plasma content and permeability compared to mouse tumors, which could contribute to differences in tumor drug uptake. Maximal antitumor effects (T/C of 0.04-0.35) were observed in both species after daily administration with similar C(max) and AUC values of unbound (free) RAD001. These free levels of RAD001 are exceeded in serum from cancer patients receiving clinically beneficial daily regimens. In rodents, brain penetration of RAD001 was poor, but was dose-dependent and showed over-proportional uptake in rats with a longer t(1/2) compared to the systemic circulation.

CONCLUSIONS

The PK of RAD001 differed between mice and rats, with rats having a PK profile closer to that of humans. High intermittent doses of RAD001 may be more appropriate for treatment of brain tumors.

Continuous and discontinuous phase transitions and partial synchronization in stochastic three-state oscillators

We investigate both continuous (second-order) and discontinuous (first-order) transitions to macroscopic synchronization within a single class of discrete, stochastic (globally) phase-coupled oscillators. We provide analytical and numerical evidence that the continuity of the transition depends on the coupling coefficients and, in some nonuniform populations, on the degree of quenched disorder. Hence, in a relatively simple setting this class of models exhibits the qualitative behaviors characteristic of a variety of considerably more complicated models. In addition, we study the microscopic basis of synchronization above threshold and detail the counterintuitive subtleties relating measurements of time-averaged frequencies and mean-field oscillations. Most notably, we observe a state of suprathreshold partial synchronization in which time-averaged frequency measurements from individual oscillators do not correspond to the frequency of macroscopic oscillations observed in the population.

Fluctuation theorem for entropy production during effusion of an ideal gas with momentum transfer

We derive an exact expression for entropy production during effusion of an ideal gas driven by momentum transfer in addition to energy and particle flux. Following the treatment in Cleuren [Phys. Rev. E 74, 021117 (2006)], we construct a master equation formulation of the process and explicitly verify the thermodynamic fluctuation theorem, thereby directly exhibiting its extended applicability to particle flows and hence to hydrodynamic systems.

Effects of disorder on synchronization of discrete phase-coupled oscillators

We study synchronization in populations of phase-coupled stochastic three-state oscillators characterized by a distribution of transition rates. We present results on an exactly solvable dimer as well as a systematic characterization of globally connected arrays of N types of oscillators (N=2,3,4) by exploring the linear stability of the nonsynchronous fixed point. We also provide results for globally coupled arrays where the transition rate of each unit is drawn from a uniform distribution of finite width. Even in the presence of transition rate disorder, numerical and analytical results point to a single phase transition to macroscopic synchrony at a critical value of the coupling strength. Numerical simulations make possible further characterization of the synchronized arrays.

Dissipation: the phase-space perspective

We show, through a refinement of the work theorem, that the average dissipation, upon perturbing a Hamiltonian system arbitrarily far out of equilibrium in a transition between two canonical equilibrium states, is exactly given by <W{diss}> =W-DeltaF=kTD(rho||rho[over ])=kT<ln(rho/rho[over ])>, where rho and rho[over ] are the phase-space density of the system measured at the same intermediate but otherwise arbitrary point in time, for the forward and backward process. D(rho||rho[over ]) is the relative entropy of rho versus rho[over ]. This result also implies general inequalities, which are significantly more accurate than the second law and include, as a special case, the celebrated Landauer principle on the dissipation involved in irreversible computations.

Ethnic sensitivity study of fingolimod in white and Asian subjects

OBJECTIVE

The authors compared the pharmacokinetics and pharmacological effects of the immunomodulator fingolimod in healthy white and Asian subjects for potential ethnic differences.

METHODS

White and Asian (Japanese) healthy subjects were demographically matched for sex, age and weight. Subjects received single 1.25 mg doses of fingolimod (6 ethnic pairs), 2.5 mg (7 pairs), 5 mg (6 pairs) or 5 mg/day for 7 days (6 pairs). The pharmacokinetics of fingolimod, major metabolites, peripheral blood lymphocyte counts and heart rate were characterized over 1 month after single-dose and 2 months after multiple-dose administration.

RESULTS

There were no clinically relevant differences in the fingolimod dose Cmax or dose AUC relationships between Asian subjects (slopes 0.84 and 1.05) versus white subjects (slopes 1.13 and 1.26) after single-dose administration. During multiple-dose administration, there were no clinically relevant interethnic differences in fingolimod accumulation ratios (6.6 +/- 0.4 for whites, 7.0 +/- 0.7 for Asians), area under the concentration-time curve (390 +/- 73 versus 382 +/- 106 ng x h/ml), or elimination half-life (7.4 +/- 0.8 versus 7.9 +/- 2.0 days). The acute decrease in lymphocyte counts after single- and multiple-dose fingolimod were similar in the two ethnic groups. The lymphocyte recovery rate to baseline after a 5 mg single dose and 5 mg/day multiple dose was reduced by 36 and 15% in Asian subjects compared with white subjects. The transient, acute decrease in heart rate after the first dose of fingolimod and the subsequent return to baseline was similar in the two ethnic groups.

CONCLUSION

There were no marked differences between healthy white and Asian subjects in fingolimod single-dose and multiple-dose pharmacokinetics, lymphocyte trafficking and heart rate responses.

Critical behavior and synchronization of discrete stochastic phase-coupled oscillators

Synchronization of stochastic phase-coupled oscillators is known to occur but difficult to characterize because sufficiently complete analytic work is not yet within our reach, and thorough numerical description usually defies all resources. We present a discrete model that is sufficiently simple to be characterized in meaningful detail. In the mean-field limit, the model exhibits a supercritical Hopf bifurcation and global oscillatory behavior as coupling crosses a critical value. When coupling between units is strictly local, the model undergoes a continuous phase transition that we characterize numerically using finite-size scaling analysis. In particular, we explicitly rule out multistability and show that the onset of global synchrony is marked by signatures of the XY universality class. Our numerical results cover dimensions d=2, 3, 4, and 5 and lead to the appropriate XY classical exponents beta and nu, a lower critical dimension dlc=2, and an upper critical dimension duc=4.

Fluctuation theorem for the effusion of an ideal gas

The probability distribution of the entropy production for the effusion of an ideal gas between two compartments is calculated explicitly. The fluctuation theorem is verified. The analytic results are in good agreement with numerical data from hard disk molecular dynamics simulations.