Outcomes of Surgical Reconstruction Using Custom 3D-Printed Porous Titanium Implants for Critical-Sized Bone Defects of the Foot and Ankle

BACKGROUND

Treating critically sized defects (CSDs) of bone remains a significant challenge in foot and ankle surgery. Custom 3D-printed implants are being offered to a small but growing subset of patients as a salvage procedure in lieu of traditional alternates such as structural allografts after the patient has failed prior procedures. The long-term outcomes of 3D-printed implants are still unknown and understudied because of the limited number of cases and short follow-up durations. The purpose of this study was to evaluate the outcomes of patients who received custom 3D-printed implants to treat CSDs of the foot and ankle in an attempt to aid surgeons in selecting appropriate surgical candidates.

METHODS

This was a retrospective study to assess surgical outcomes of patients who underwent implantation of a custom 3D-printed implant made with medical-grade titanium alloy powder (Ti-6Al-4V) to treat CSDs of the foot and ankle between June 1, 2014, and September 30, 2019. All patients had failed previous nonoperative or operative management before proceeding with treatment with a custom 3D-printed implant. Univariate and multivariate odds ratios (ORs) of a secondary surgery and implant removal were calculated for perioperative variables.

RESULTS

There were 39 cases of patients who received a custom 3D-printed implant with at least 1 year of follow-up. The mean follow-up time was 27.0 (12-74) months. Thirteen of 39 cases (33.3%) required a secondary surgery and 10 of 39 (25.6%) required removal of the implant because of septic nonunion (6/10) or aseptic nonunion (4/10). The mean time to secondary surgery was 10 months (1-22). Multivariate logistic regression revealed that patients with neuropathy were more likely to require a secondary surgery with an OR of 5.76 (P = .03).

CONCLUSION

This study demonstrated that 74% of patients who received a custom 3D-printed implant for CSDs did not require as subsequent surgery (minimum of 1-year follow-up). Neuropathy was significantly associated with the need for a secondary surgery. This is the largest series to date demonstrating the efficacy of 3D-printed custom titanium implants. As the number of cases using patient-specific 3D-printed titanium implant increases, larger cohorts of patients should be studied to identify other high-risk groups and possible interventions to improve surgical outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Sweet corn cob as a functional ingredient in bakery products

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Incorporation of sweet corn cob flour (SCCF) in gluten free rice muffin was examined.

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SCCF contained a higher amount of ferulic acid and dietary fiber than rice flour.

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Muffin incorporated with 10% and 20% of SCCF showed an improvement in texture.

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Baking increases the free ferulic acid in muffin incorporated with SCCF.

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Muffin with SCCF showed higher mean overall liking scores in consumers liking test.

Gluten free (GF) products are often inferior in quality attributes, nutritional content and consumer acceptability. The use of GF by-products is a novel strategy to improve the structure and nutritional profile of these products. Sweet corn cob (SCC) is a by-product of sweet corn processing containing a considerable amount of fibre and ferulic acid. The effect of baking on ferulic acid content, colour, texture and physical characteristics on muffins incorporated with SCC flour (SCCF) as a value-added food ingredient was investigated using a GF model system. The freeze-dried SCCF, containing ferulic acid (6.02 mg g⁻¹) was used to replace the rice flour at varying levels of 10, 20, and 30%. In general, SCCF increased dietary fibre and free ferulic acid content of muffins. Inclusion of 20% SCCF showed an increase in terms of the height of the muffin and number of air cells in the crumb, along with a decrease in the hardness of muffins. Muffins with SCCF showed higher mean overall liking scores than rice flour muffin.

0092 A Daytime Nap Restores Hippocampal Function and Improves Declarative Learning

Introduction

Daytime naps have been shown to improve learning outcomes. One theory underlying enhanced encoding following a nap is via the synaptic downscaling of neurons potentiated during wake - a process facilitated by slow oscillations. In this study, we sought to investigate neural mechanisms underlying enhanced encoding following a nap compared to a waking period using a combination of PSG and fMRI methods.

Methods

40 healthy undergraduates (M=23.3y, SD=2.96y; 10 males) who slept normally the previous night encoded word pair lists across 2 runs in an MRI scanner at 1PM and 4.30PM. In between encoding sessions, participants either stayed awake and watched a documentary (Wake group; N=20), or napped for 90-min while undergoing polysomnography (Nap group; N=20). Approximately 40min after each encoding session, memory of these word lists were assessed in a cued-recall fashion. Performance in each session was measured by percentage of correct responses.

Results

There were no baseline differences in encoding performance. However, a Session x Group interaction effect (p<0.001) was observed whereby performance significantly improved only in the Nap group in the second encoding session (Nap:20±19% vs. Wake:-1±13%). Concurrent to this, fMRI analyses revealed a Session x Run x Group interaction effect in the hippocampus (p=0.002) whereby hippocampal activation during encoding of the word lists increased only in the Nap group. In addition, although there was no association between degree of performance improvement in the nap group with duration of sleep or the various sleep stages (N1,N2,N3,REM), spindle count (12-15Hz) in the Nap group correlated significantly with both performance improvement (rs=0.46) and increase in hippocampal activation (rs=0.46).

Conclusion

These results confirm the benefit of a nap on encoding processes. Hippocampal activation also increased following the nap, which could indicate renewed hippocampal capacity to store new information. While we hypothesized that slow wave sleep would aid in this transfer, we instead found a relationship between spindle count and both degree of performance improvement and increase in hippocampal activation. The interplay between NREM sleep oscillations, hippocampal downscaling and encoding performance could be more complex than originally thought.

Support

National Medical Research Council, Singapore (NMRC/STaR/015/2013) and the Far East Organization.

A multiplexed microfluidic system for evaluation of dynamics of immune-tumor interactions

Recapitulation of the tumor microenvironment is critical for probing mechanisms involved in cancer, and for evaluating the tumor-killing potential of chemotherapeutic agents, targeted therapies and immunotherapies. Microfluidic devices have emerged as valuable tools for both mechanistic studies and for preclinical evaluation of therapeutic agents, due to their ability to precisely control drug concentrations and gradients of oxygen and other species in a scalable and potentially high throughput manner. Most existing in vitro microfluidic cancer models are comprised of cultured cancer cells embedded in a physiologically relevant matrix, collocated with vascular-like structures. However, the recent emergence of immune checkpoint inhibitors (ICI) as a powerful therapeutic modality against many cancers has created a need for preclinical in vitro models that accommodate interactions between tumors and immune cells, particularly for assessment of unprocessed tumor fragments harvested directly from patient biopsies. Here we report on a microfluidic model, termed EVIDENT (ex vivo immuno-oncology dynamic environment for tumor biopsies), that accommodates up to 12 separate tumor biopsy fragments interacting with flowing tumor-infiltrating lymphocytes (TILs) in a dynamic microenvironment. Flow control is achieved with a single pump in a simple and scalable configuration, and the entire system is constructed using low-sorption materials, addressing two principal concerns with existing microfluidic cancer models. The system sustains tumor fragments for multiple days, and permits real-time, high-resolution imaging of the interaction between autologous TILs and tumor fragments, enabling mapping of TIL-mediated tumor killing and testing of various ICI treatments versus tumor response. Custom image analytic algorithms based on machine learning reported here provide automated and quantitative assessment of experimental results. Initial studies indicate that the system is capable of quantifying temporal levels of TIL infiltration and tumor death, and that the EVIDENT model mimics the known in vivo tumor response to anti-PD-1 ICI treatment of flowing TILs relative to isotype control treatments for syngeneic mouse MC38 tumors.

Health-Related Quality of Life in Patients Treated with Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis in Singapore

OBJECTIVE

This study aimed to compare the health-related quality of life (HRQOL) in patients with end-stage renal disease (ESRD) treated with continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) in Singapore.

METHODS

The data used in this study were from two cross-sectional surveys of ESRD patients. HRQOL was assessed using the Kidney Disease Quality of Life (KDQOL) instrument. Socio-demographic characteristics and clinical data were collected. The physical component summary (PCS) and mental component summary (MCS) scores, kidney disease component summary (KDCS) score and its three scales (symptoms, effects, burden), and one health utility score [EuroQol 5-dimension (EQ-5D)] were calculated and compared between CAPD and APD using multivariate linear regression.

RESULTS

In total, 266 patients were included, with 145 on CAPD (mean age 60.8 years) and 121 on APD (mean age 57.4 years). After adjustment for all variables collected, APD patients had significant higher scores in PCS and KDQOL symptoms than CAPD patients, suggesting that APD was associated with better physical health and milder dialysis-related symptoms.

CONCLUSION

The HRQOL of CAPD and APD patients was largely equivalent in Singapore, but APD patients seemed to experience better physical health and be less bothered by dialysis-related symptoms.

Stress-induced structural plasticity of medial amygdala stellate neurons and rapid prevention by a candidate antidepressant

The adult brain is capable of adapting to internal and external stressors by undergoing structural plasticity, and failure to be resilient and preserve normal structure and function is likely to contribute to depression and anxiety disorders. Although the hippocampus has provided the gateway for understanding stress effects on the brain, less is known about the amygdala, a key brain area involved in the neural circuitry of fear and anxiety. Here, in mice more vulnerable to stressors, we demonstrate structural plasticity within the medial and basolateral regions of the amygdala in response to prolonged 21-day chronic restraint stress (CRS). Three days before the end of CRS, treatment with the putative, rapidly acting antidepressant, acetyl-l-carnitine (LAC) in the drinking water opposed the direction of these changes. Behaviorally, the LAC treatment during the last part of CRS enhanced resilience, opposing the effects of CRS, as shown by an increased social interaction and reduced passive behavior in a forced swim test. Furthermore, CRS mice treated with LAC show resilience of the CRS-induced structural remodeling of medial amygdala (MeA) stellate neurons. Within the basolateral amygdala (BLA), LAC did not reduce, but slightly enhanced, the CRS-increased length and number of intersections of pyramidal neurons. No structural changes were observed in MeA bipolar neurons, BLA stellate neurons or in lateral amygdala stellate neurons. Our findings identify MeA stellate neurons as an important component in the responses to stress and LAC action and show that LAC can promote structural plasticity of the MeA. This may be useful as a model for increasing resilience to stressors in at-risk populations.

Health-related quality of life of Asian patients with end-stage renal disease (ESRD) in Singapore

BACKGROUND

This study aimed to identify factors associated with the health-related quality of life (HRQOL) of multiethnic Asian end-stage renal disease (ESRD) patients treated with dialysis. The role of dialysis modality was also explored.

METHODS

Data used in this study were from two cross-sectional surveys of Singaporean ESRD patients on haemodialysis (HD) or peritoneal dialysis (PD). In both surveys, participants were assessed using the kidney disease quality of life (KDQOL) instrument and questions assessing socio-demographic characteristics. Clinical data including co-morbidity (measured by Charlson comorbidity index [CCI]), albumin level, haemoglobin level, and dialysis-related variables (e.g. dialysis vintage and dialysis adequacy) were retrieved from medical records. The 36-item KDQOL (KDQOL-36) was used to generate three summary scores (physical component summary [PCS], mental component summary [MCS] and kidney disease component summary [KDCS]) and two health utility scores (Short Form 6-dimension [SF-6D] and EuroQol 5-dimension [EQ-5D]). Linear regression analysis was performed to examine the association of factors with each of the HRQOL scale scores.

RESULTS

Five hundred and two patients were included in the study (mean age 57.1 years; male 52.4 %; HD 236, PD 266). Mean [standard deviation (SD)] PCS, MCS and KDCS scores were 37.9 (9.7), 46.4 (10.8) and 57.6 (18.1), respectively. Mean (SD) health utility score was 0.66 (0.12) for SF-6D and 0.60 (0.21) for EQ-5D. In multivariate regression analysis, factors found to be significantly associated with better HRQOL included: young (<45 years) or old age (>60 years), low CCI (<5), high albumin (≥37 g/l) and high haemoglobin (≥11 g/dl) with PCS; long dialysis vintage (≥3.5 years) with MCS; old age, Malay ethnicity and PD modality with KDCS; low CCI, high albumin and high haemoglobin with EQ-5D and high albumin with SF-6D.

CONCLUSIONS

Clinical characteristics are better predictors of HRQOL in ESRD patients than socio-demographics in Singapore. Dialysis modality has no impact on the health utility of those patients.

The impact of a multifaceted ergonomic intervention program on promoting occupational health in community nurses

INTRODUCTION

Community nurses are exposed to high physical demands at work resulting in musculoskeletal disorders. The present study examined the short- and long-term benefits of a multifaceted intervention program designed especially for community nurses in Hong Kong.

METHODS

Fifty community nurses working in 4 local hospitals participated in the study. All of them underwent an 8-week intervention program consisting of ergonomic training, daily exercise program, equipment modification, computer workstation assessment and typing training.

RESULTS

All participants showed significant improvement in musculoskeletal symptoms and functional outcomes comparing pre- and post-intervention results. Significant reduction in symptom score was observed at 1-year follow-up compared to post-intervention. Symptomatic group (n=40) showed more significant changes overall compared to asymptomatic group (n=10).

CONCLUSION

Results support the positive benefits, both short- and long-term, of the multifaceted ergonomic intervention programme for community nurses.

Swelling in the upper arm: the presentation and management of an isolated brachial artery aneurysm

True aneurysms of the brachial artery are uncommon. We describe the presentation and surgical management of an isolated, brachial artery aneurysm in a 64-year-old woman. Excision of the aneurysm and long saphenous venous interposition grafting was performed with no postoperative complications and histology demonstrated true aneurysmal degeneration.

A dopamine transporter mutation associated with bipolar affective disorder causes inhibition of transporter cell surface expression

The dopamine transporter (DAT) plays a crucial role in dopaminergic neurotransmission as it clears the extracellular space of dopamine (DA) and thus controls the concentration of active neurotransmitter. Genetic association studies have reported a variable number of tandem repeat polymorphisms in the 3'-noncoding region of the DAT gene implicating this protein in the development of various psychiatric disorders. In a sample of bipolar patients, two rare missense substitutions (A559V and E602G) have been identified, one of which (E602G) was inherited by the patient from her affected father. None of these mutations had been identified in any control subjects of this survey. Using a heterologous cellular expression system, we have analysed possible consequences of these mutations on functional properties of the encoded DAT protein. DA transport measurements and antagonist binding revealed that the A559V mutant protein is fully functional, whereas the E602G mutant is not. Further analyses by confocal microscopy showed that the E602G protein is transcribed and translated but not delivered to the cell surface. Taken together, our results suggest that this missense mutation has functional consequences thus supporting the need to screen larger samples of patients and their relatives for this rare but bipolar disorder-associated mutation in the DAT gene.

Angiotensin II type 1 receptor inhibition markedly improves the blood perfusion, oxygen tension and first phase of glucose-stimulated insulin secretion in revascularised syngeneic mouse islet grafts

AIMS/HYPOTHESIS

We recently found evidence of an angiotensin-generating system in pancreatic islets. The present study investigated the effect of endogenously produced angiotensin II on microcirculation and function in transplanted islets.

MATERIALS AND METHODS

Losartan, an angiotensin II type 1 receptor inhibitor, was administered either acute intravenously to mice with 4-week-old islet renal subcapsular transplants, or added to the drinking water for the final 14 days or throughout the 4-week post-transplantation period. The graft-bearing kidney was, in some cases, dissected out and perfused in vitro to evaluate the effect of angiotensin II and losartan on glucose-stimulated insulin release from the grafts.

RESULTS

Losartan treatment throughout the 4-week post-transplantation period had negative effects on islet revascularisation as well as on islet graft insulin release. However, administration of losartan, either intravenously or orally, after the formation of a new vascular network, improved islet graft blood perfusion. PO2 in the islet transplants was also effectively improved by the losartan treatment. Graft perfusion experiments showed a markedly better first phase of glucose-stimulated insulin release in transplanted islets when exposed to losartan. In contrast, acute administration of angiotensin II decreased islet graft blood flow, PO2 and glucose-stimulated insulin release.

CONCLUSIONS/INTERPRETATION

This study shows that inhibition of the islet reninangiotensin system may be a feasible strategy to increase the blood perfusion, PO2 and function within islet grafts. Such treatment should not be initiated, however, before the islet vascular system has been formed.

Evidence for a local angiotensin-generating system and dose-dependent inhibition of glucose-stimulated insulin release by angiotensin II in isolated pancreatic islets

AIMS/HYPOTHESIS

A local angiotensin-generating system has been found in the exocrine pancreas. This study aimed, primarily, to investigate the existence of a local angiotensin-generating system in the pancreatic islets and, secondly, to elucidate its role in regulating insulin secretion.

METHODS

Real-time RT-PCR and western blot were used to investigate if angiotensin-generating components are present in the mouse pancreatic islets, which are subject to regulation by islet transplantation. The localisation of AT1-receptors in islets was investigated by immunohistochemistry. Batch-type incubations of isolated islets were applied for studying the influence of angiotensin II on the glucose-stimulated insulin release, glucose oxidation and (pro)insulin, and total protein biosynthesis.

RESULTS

Major components, namely angiotensinogen, ACE, AT1- and AT2-receptors, were expressed in endogenous islets. AT1-receptors were localised to pancreatic beta cells. Exposure of the isolated islets to angiotensin II induced a dose-dependent inhibition of glucose-stimulated insulin release and inhibited (pro)insulin biosynthesis. This inhibitory action was fully preventable by pretreatment of the islets with losartan, an AT1-receptor antagonist. We also investigated if the expression of these components was changed after islet transplantation. Notably, a markedly increased expression of mRNA for the AT1-receptor was observed in islets retrieved from 4-week-old syngeneic islet transplants, a finding that was confirmed at the protein level.

CONCLUSION/INTERPRETATION

These data indicate the existence of an islet angiotensin-generating system of potential importance in the physiological regulation of glucose-induced insulin secretion, thus diabetes mellitus. The increased expression of the AT1-receptor in islet transplants could have relevance to islet-graft function.

Disruptions to women's social identity: a comparative study of workplace stress experienced by women in three geographic regions

Drawing on social identity theory (P. J. Burke, 1991) and the current status of women and equal opportunity legislation, the authors tested several factors associated with distress in working women in the People's Republic of China (PRC), Hong Kong, and the United States. Women in Hong Kong experienced significantly greater levels of life stress than PRC and U.S. women. Reports of negative attitudes toward women, gender evaluation, and avoidance coping were greater for Hong Kong and PRC women than for U.S. women. Hong Kong women reported more use of positive/confrontational coping mechanisms. Negative attitudes toward women had an important influence on life stress across regions. Moderator tests resulted in 2 significant findings: The effect of negative attitudes toward women on life stress was stronger for PRC and Hong Kong women, and the relationship between nervous/self-destructive coping and life stress was stronger for U.S. women.

Arginine, citrulline, and nitric oxide metabolism in end-stage renal disease patients

The kidneys are thought to be a major site of net de novo arginine synthesis, but the quantitative status of arginine metabolism and its substrate precursor relationship to nitric oxide (NO) synthesis in end stage renal disease (ESRD) patients have not been characterized. We have investigated kinetic aspects of whole body arginine metabolism in six patients with ESRD. They received two pre- and two post-hemodialysis intravenous tracer infusion studies with L-[guanidino-(15)N(2)]arginine and L-[(13)C]leucine during the first study, and L-[5-(13)C]arginine and L-[5-(13)C-ureido,5,5, (2)H(2)]citrulline during the second study. Arginine homeostasis in ESRD patients was found to be associated with a lower rate of arginine oxidation, and despite the decrease in renal function, the rate of de novo arginine synthesis appeared to be preserved. Plasma citrulline concentrations and flux were also elevated in these subjects compared with healthy adults. The rate of whole body NO synthesis was increased in the ESRD patients, but apparently not different pre- and post-hemodialysis therapy. The anatomic site(s) responsible for the maintenance of net de novo arginine synthesis and for the elevated NO synthesis and its pathophysiological importance in ESRD remain to be established.

Amantadine in depressive patients with Borna disease virus (BDV) infection: an open trial

OBJECTIVE

Originally introduced into pharmacotherapy as an antiviral compound, amantadine was shown to also have multiple pharmacological eftfects on the central nervous system. In addition. only a few studies reported on certain antidepressive properties of amantadine. This effect was highlighted by the discovery of its antiviral effect on Borna disease virus (BDV), which is hypothesized to be an etiopathogenetic factor to subtypes of affective disorders. Therefore, the therapeutical use of amantadine in BDV-infected depressive patients was investigated.

METHODS

In this open trial, amantadine was added to antidepressive and or mood-stabilizing compounds treating BDV-infected depressed patients (n = 25) with bipolar or major depressive disorders. Amantadine was given twice a day (100-300 mg/day) for a mean of 11 weeks. Antidepressive treatment response was measured on the Hamilton rating scale for depression (HAM-D) and/or with an operationalized diagnostic criteria system (OPCRIT: version 3.31). Virological response was measured by expression of BDV infection parameters in blood samples.

RESULTS

The overall response rate of the amantadine augmentation in the BDV-infected patients with regard to depressive symptoms was 68% after a mean of 2.9 weeks of treatment. Bipolar I patients improved faster and did not show any following hypomania. In addition, the decrease of depression tended to correspond with the decrease in viral activity.

CONCLUSION

Amantadine appears to show a remarkable antidepressive efficacy in BDV-infected depressive patients. The antidepressive effect in this open trial appeared to be comparable to standard antidepressives, possibly being a result of its antiviral effect against BDV as a potentially relevant etiopathogenetic factor in these disorders.

Maternal serum screening for Down syndrome in a teaching hospital in Hong Kong

OBJECTIVE

To study prospectively the use of maternal serum alpha-fetoprotein (AFP) and total beta-human chorionic gonadotropin (hCG) concentrations for screening of Down syndrome in Hong Kong.

METHODS

AFP and total beta-hCG were measured in serum samples from 1638 singleton Chinese pregnancies at 14-22 weeks of gestation, recruited over a twelve-month period. Gestational ages were determined by ultrasonographic parameters measured at the same visit as the test for all cases. The gestational-age-specific and weight-adjusted medians for serum AFP and total beta-hCG were calculated. Risk for fetal Down syndrome (FDS) was derived by mathematical modeling of the medians together with maternal age. Amniocenteses were offered to women with a calculated FDS risk of 1:270 or greater.

RESULTS

The gestational-age-specific and weight-adjusted medians for maternal serum AFP were similar to previous studies while that of total beta-hCG were higher. A total of 101 patients (6.1%) were classified as being high risk for FDS, including 3.4% (48/1394) of those younger than 35 years of age and 21.7% (53/244) of those who were 35 or above. There were 4 cases of Down syndrome, 1 case of Tumer syndrome and 1 of Edward syndrome. Three out of the four cases of Down syndrome were screened positive, corresponding to a detection rate of FDS of 75%. A case of Tumer syndrome was also screened positive. A case of trisomy 18 was found to have very low levels of AFP [0.262 multiple of median (MoM)] and total beta-hCG (0.115 MoM).

CONCLUSIONS

Maternal serum screening using double biochemical markers (AFP and total beta-hCG) in combination with gestational dating by ultrasonography is effective in the detection of fetal Down syndrome and possibly other chromosomal disorders in Chinese pregnant women.

Characterization of novel inhibitors of cyclin-dependent kinases

In epithelial cells progression through the G1 phase of the cell cycle and preparing the cell for the S phase is regulated by cyclin D1-cdk4. Cells that express the retinoblastoma protein (pRb) are dependent on cyclin D1-cdk4 activity for their proliferation while cells that do not express pRb are not. Overexpression of cyclin D1 and/or cdk4, and loss of expression of p16 (the natural inhibitor of cyclin D1-cdk4 activity), have been implicated in several cancers. These data suggest that the aberrant activity of cyclin D1-cdk4 correlates with the tumor phenotype. Hence, blocking cyclin D1-cdk4 activity may prove to be an effective anticancer therapy for pRb(+) tumors. In this paper, we report the identification of four novel compounds that selectively inhibit cyclin D1-cdk4 activity to various degrees. We further demonstrate that two of these compounds also selectively inhibit the target, pRb(+) tumor cells. The implications of these discoveries and their utility as anticancer agents are discussed.

Z extensions to the RHMAPPER package

MOTIVATION

Extensions have been made to the RHMAPPER-1.1 package. One set of extensions computes the totally linked markers and uses the results as input to the salient RHMAPPER functions. The second set of extensions uses TKperl to provide an interactive interface for ease of querying the database and displaying maps.

AVAILABILITY

The extensions can be obtained via ftp.sanger.ac.uk/pub/zmapper.

SUPPLEMENTARY INFORMATION

The User's Manual can be viewed from http:/www.sanger.ac.uk/Users/cari/Z.shtml.

CONTACT

cari@sanger.ac.uk

Injection of autologous blood for bleb leaks in New Zealand white rabbits

PURPOSE

Bleb leaks after trabeculectomy with antimetabolites can be recalcitrant to therapy. Peribleb autologous blood injections are a moderately successful new treatment modality for such leaks. However, it is unclear what mechanism the injections work to achieve leak resolution.

METHODS

A randomized, prospective study in the rabbit model was undertaken to evaluate further the clinical and histologic effects of peribleb autologous blood injection after leak induction in mitomycin-C exposed blebs, compared to controls that received only peribleb balanced salt solution injections.

RESULTS

In the blood-treated eyes, all bleb leaks healed. Control eyes either demonstrated persistent bleb leaks with shallow anterior chambers or failed blebs that were Seidel negative. Histologic results were remarkable for increased peribleb cellularity and collagen deposition in the blood-treated eyes, compared to controls.

CONCLUSIONS

Peribleb autologous blood injections are associated with bleb leak resolution, increased peribleb cellularity, and collagen deposition in the rabbit model.

[Hot water irrigation in the treatment of posterior epistaxis]

Tamponade treatment in epistaxis is painful and the patient needs hospitalisation. Irrigation with hot water was introduced as a treatment of epistaxis 100 years ago. This study compares the two treatments with respect to effect, recurrence, pain, and length of hospital stay. Forty-four consecutive patients with posterior epistaxis were randomized to receive treatment with either hot water (HWI) or tamponade. In the group of patients treated with HWI, the treatment had to be stopped in seven patients (33%) because of lack of cooperation; nine patients (43%) could be discharged from hospital with no need for further treatment, whereas five patients (24%) had recurrent epistaxis requiring additional tamponade treatment. Among patients treated with tamponade, 14 patients (61%) could be discharged from hospital with no need for further treatment, while nine patients (39%) had recurrent epistaxis requiring additional tamponade treatment. Compared with the tamponade treatment, HWI is almost as effective, the hospital stay is shorter, and the treatment is significantly less painful.

Hot-water irrigation as a treatment of posterior epistaxis

The commonly-used tamponade treatment for posterior epistaxis is painful and the patient may need hospitalization for several days. Irrigation with water of 50 degrees C was introduced as a treatment for posterior epistaxis more than 100 years ago. This study compares the two treatment modalities with respect to effect, recurrence, pain, and length of hospital stay. Forty-four consecutive patients with posterior epistaxis were randomized to receive treatment with either hot water (21 patients) or tamponade (23 patients). In the group of patients treated with hot water, the treatment had to be stopped in seven patients (33%) because of lack of cooperation; nine patients (43%) could be dismissed from hospital with no need for further treatment, whereas five patients (24%) had recurrent epistaxis requiring additional tamponade treatment. Among the patients treated with tamponade, 14 patients (61%) could be dismissed from hospital with no need for further treatment, while nine patients (39%) had recurrent epistaxis requiring additional tamponade treatment. The median stay in hospital was five days for the group treated with hot water, and six days for the group treated with tamponade. Compared to the tamponade treatment, hot-water irrigation is almost as effective, the hospital stay is shorter, and the treatment is significantly less painful.

Sagittal plane rotation of the pelvis during lumbar posteroanterior loading

OBJECTIVE

To determine the extent of sagittal plane rotation of the pelvis during lumbar spine posteroanterior loading.

DESIGN

Quantitative study.

SETTING

Biomechanics Laboratory, Faculty of Health Sciences, University of Sydney.

PARTICIPANTS

Ten male and female subjects with no recent history of significant low back pain.

INTERVENTION

A mechanical device was used to apply forces to the L3 spinous process. Data were collected during slow cyclical loading.

MAIN OUTCOME MEASURE

The stiffness of the posteroanterior movement at the point of loading was measured, together with the sagittal plane rotation of the pelvis and the resistance to rotation provided by the bed on which the subject lay.

RESULTS

Mean pelvic rotation was 2.1 degrees per 100 N applied force (SD 1.01 degrees/100 N). Mean posteroanterior stiffness was 13.4 N/mm (SD 3.13 N/mm) and resistance to pelvic rotation was 2.71 Nm/degree of pelvic rotation (SD 0.84 Nm/degree).

CONCLUSION

During posteroanterior force application there is pelvic rotation of a magnitude that may be sufficient to have clinical significance. Abnormalities found during lumbar posteroanterior force application may originate in tissues caudad to the lumbar spine itself.

Higher-order kappa-type statistics for a dichotomous attribute in multiple ratings

We introduce a sequence of parameters called canonical moments to characterize the predictive value of the pattern of consensus among (kappa-1) ratings to an additional rating. The usual kappa coefficient of agreement among ratings (two or more) is just the second canonical moment. By using the higher canonical moments, we can evaluate the consensus of multiple binary ratings.

Tympanosclerosis of the middle ear: late results of surgical treatment

The late results of one stage operation for middle ear tymanosclerosis in 73 patients during the period January 1965 to December 1980 are presented. Mean observation time was 11.2 years (range 3-20.2 years), with a follow-up rate 86 per cent. Among 64 patients with stapes fixation, 59 had removal of tympanosclerotic masses and stapes mobilization, and five cases underwent stapedectomy. The series was divided into six groups and the results analyzed. The best and most stable results occurred in the group with stapes mobilization and an intact ossicular chain followed by the group with stapes mobilization and Type II tympanoplasty with incus interposition. The poorest late results were obtained in ears with lacking stapes crura and stapes mobilization, and in ears subjected to stapedectomy. No case of post-operative sensorineural hearing loss occurred. We recommend that care is taken to preserve an intact ossicular chain at stapes mobilization performed at the same stage as myringoplasty. Also in ears with a defective ossicular chain but intact stapes with tympanosclerotic fixation we recommend stapes mobilization in one stage. In ears with fixation of the stapes footplate and defective crura, we recommend stapedectomy or stapedotomy in two stages.

Patterns of metastasis in uterine sarcoma. An autopsy study

The autopsy findings of 73 patients with uterine sarcoma were studied to determine the sites and possible modes of metastasis. Homologous mixed mesodermal tumors were the most frequent (41%) followed by leiomyosarcoma (26%), heterologous mixed mesodermal tumor (18.3%), stromal sarcoma (12%), and endolymphatic stromal myosis (3%). The peritoneal cavity and omentum were the most frequently involved sites (59%), followed by the lung (52%), pelvic lymph nodes (41%), paraaortic lymph nodes (38%), and liver parenchyma (34%). The presence of lung metastasis was not associated with pelvic or paraaortic node metastasis or intraperitoneal disease. Metastasis to other distant sites including the brain, heart, kidney, and bone were independent of pelvic and paraaortic nodal metastasis or intraperitoneal disease. Metastatic sites were not different among various histologic types. Distant metastatic sites were statistically associated with lung metastasis. Hematogenous metastasis best explains this metastatic pattern and adjuvant systemic therapy seems indicated.

Patterns of metastasis in uterine sarcoma. An autopsy study

The autopsy findings of 73 patients with uterine sarcoma were studied to determine the sites and possible modes of metastasis. Homologous mixed mesodermal tumors were the most frequent (41%) followed by leiomyosarcoma (26%), heterologous mixed mesodermal tumor (18.3%), stromal sarcoma (12%), and endolymphatic stromal myosis (3%). The peritoneal cavity and omentum were the most frequently involved sites (59%), followed by the lung (52%), pelvic lymph nodes (41%), paraaortic lymph nodes (38%), and liver parenchyma (34%). The presence of lung metastasis was not associated with pelvic or paraaortic node metastasis or intraperitoneal disease. Metastasis to other distant sites including the brain, heart, kidney, and bone were independent of pelvic and paraaortic nodal metastasis or intraperitoneal disease. Metastatic sites were not different among various histologic types. Distant metastatic sites were statistically associated with lung metastasis. Hematogenous metastasis best explains this metastatic pattern and adjuvant systemic therapy seems indicated.

Tensa retraction cholesteatoma: treatment and long-term results

To obtain the best possible results of treatment of acquired cholesteatoma, we made a subdivision of cholesteatoma types into attic and pars tensa cholesteatomas, and subdivided the latter further into tensa retraction cholesteatoma and sinus cholesteatomas. Tensa retraction cholesteatoma is defined as arising from a retraction or perforation of the whole pars tensa, whereas sinus cholesteatoma is defined as arising from a retraction or perforation of the postero-superior part of the tensa. We present the long-term results obtained in tensa retraction cholesteatomas treated with one stage surgery from 1964 to 1980. Median observation time was 9 years, range 2 to 19 years. Sixty-one ears were treated without mastoidectomy, whereas 71 ears had canal wall-up mastoidectomy and 64 ears had canal wall-down mastoidectomy. The total recurrence rate was 13.3 per cent; 17 ears had residual cholesteatoma, and nine ears had recurrent cholesteatoma. The best results were obtained in ears with an intact ossicular chain where mastoidectomy was not performed. In 49 per cent of the cases, the cholesteatoma was confined to the tympanic cavity without reaching the aditus, antrum or mastoid process. About one-third to one-quarter of the ears had tympanoplasty only, with removal of the cholesteatoma through the ear canal.

Stability of tympanoplasty in children

The results of tympanoplasty performed for noncholesteatomatous chronic otitis in children aged 2 to 14 years are described. The authors report that the stability of hearing was excellent; they found hearing to be equally good in young children and in older children. Tympanic membrane perforation can be closed at any age. There is no age limit below which perforation should not be closed.

Hearing after surgery for cholesteatoma using various techniques

The late results in 740 patients with cholesteatoma subjected to one-stage canal wall down mastoidectomy (262 patients), modified canal wall up mastoidectomy (324 patients), and tympanoplasty without mastoidectomy (154 patients) were analyzed with regard to hearing and the condition of the drum. Mean observation time was 9.3 years, range 3-21 years. Postoperative hearing (air bone gap and pure tone average) and as hearing at the last evaluation was significantly better in the canal wall up group, than in the canal wall down group, but also the preoperative hearing was better in the canal wall up group. The postoperative hearing was best in the group with tympanoplasty only without mastoidectomy. It is concluded that no single method is optimal in all cases of cholesteatoma and that cholesteatoma surgery should be individualized.

Late results of surgery in different cholesteatoma types

Our series of 740 cholesteatomas, operated during the period 1969 to 1980, were seen at follow-up several times with a median observation period of 9.2 years (range 3-21 years). There were; 273 attic cholesteatomas with retraction (perforation) of Shrapnell's membrane; 271 sinus cholesteatomas with superioposterior retraction (perforation) of pars tensa, and 196 tensa retraction cholesteatomas extending from a retraction of the whole pars tensa. The late results were analyzed for each type separately, and compared. The recurrence rate was lowest (6.6%) in attic cholesteatoma and highest (13.3%) in tensa retraction cholesteatoma. In all three types no residual cholesteatomas were detected after the 4th postoperative year, whereas recurrent cholesteatomas occurred up to 10 years after surgery. The reoperation rate was lowest (15%) in attic cholesteatoma and almost the same (21%) in sinus and tensa retraction cholesteatoma. The hearing results were best in attic cholesteatoma and poorest in tensa retraction cholesteatoma. It is concluded that cholesteatoma surgery should be individualized and that both the canal wall up and canal wall down methods have their place in cholesteatoma surgery.

Treatment of sinus cholesteatoma. Long-term results and recurrence rate

We classified cholesteatomas as attic cholesteatoma, developing from Shrapnell's membrane; tensa cholesteatoma, originating in pars tensa, which is subdivided into tensa retraction cholesteatoma involving the entire pars tensa, and sinus cholesteatomas, developing from a posterosuperior retraction (perforation). From 1964 to 1980, one-stage operations were carried out on 271 ears with sinus cholesteatomas. Follow-up included 90% of the patients, and the median observation time was 9.75 years. The recurrence rate was 10%. The recurrence rate was found to be independent of the mastoidectomy type employed. The best hearing results were obtained in ears with intact ossicular chain. We conclude that, wherever possible, sinus cholesteatoma should be removed through the auditory canal without mastoidectomy just as an intact ossicular chain should be preserved. "Canal wall up" and "canal wall down" appear to be equally valuable mastoidectomy types, and both methods must be employed to obtain optimum results.

Attic cholesteatoma. Recurrence rate related to observation time

Two hundred twenty-four ears with attic cholesteatomas, subjected to one-stage surgery between 1965 and 1978, were reevaluated several times, most recently in 1980/81 at a median observation time of 8 years (range, 3 to 16 years) and in 1985/86 at a median observation time of 11 years (range, 3 to 21 years). The recurrence rate was related to length of observation time. Up to and including the follow-up examination in 1980, the rate of residual cholesteatoma in the tympanic cavity was 1.3% and 0.9% in the attic. The incidence of recurrent cholesteatoma in the attic or the cavity was 1.8%. The total recurrence rate was 4.0%. At follow-up in 1985/86, the total recurrence rate had increased to 6.3%, comprising residual cholesteatoma in the tympanic cavity in 1.8% and in the attic in 0.9% and recurrent cholesteatoma in 3.6%. A total of 133 patients had a modified canal wall up mastoidectomy, whereas 91 patients had canal wall down mastoidectomy with obliteration. With regard to the total results of surgery, no significant differences could be demonstrated between the two methods, and we conclude that canal wall up mastoidectomy can be performed in one stage.

Conservative therapy for melanoma of the vulva

Recent cooperative studies have demonstrated that less radical local resection of cutaneous melanomas is equally effective as a traditional radical approach. A retrospective review of vulvar melanoma was undertaken to determine if mode of therapy affected recurrence. Survival correlated independently with depth of invasion and age (p = 0.05 and p less than 0.02, respectively). In the comparison of radical vulvectomy with local excision, no patient differences in age or histopathologic variables were determined (nodal disease status, histology, mitotic count, lymphocytic infiltration, or ulceration). Radical vulvectomy did not improve survival over local therapy (p greater than 0.2). Six of eight patients whose melanoma had less than 2 mm of invasion treated with local therapy are disease free after a median of 127 months (range 6 to 300 months). For local excision, recurrences were more frequent when margins were less than 2 cm, but this was not statistically significant in this small sample. Although the current series is small and retrospective, its findings suggest that treatment recommendations of large cutaneous nonvulvar melanoma studies are applicable to vulvar melanoma. A prospective randomized study of radical versus conservative surgery for vulvar melanoma will be necessary to confirm these treatment recommendations.