Citations

Objectives: Femoral nerve blockade has become a popular method of postoperative analgesia for anterior cruciate ligament (ACL) reconstruction in pediatric and adolescent patients. Successful rehabilitation after ACL reconstruction involves return of quadriceps and hamstring strength and dynamic knee stability. The objective of this study was to compare strength and function six months after ACL reconstruction in pediatric and adolescent patients who received a femoral nerve block versus a control group of patients with no nerve block. Methods: A search of our institutional database was performed to identify patients 17 years of age or younger who underwent primary ACL reconstruction between 2001 and 2010. Revision ACL surgeries and previous contralateral and ipsilateral knee surgeries were excluded. Based on institutional protocol, the patients participated in a comprehensive rehabilitation program and underwent isokinetic strength testing (slow and fast activation) and functional testing (vertical jump, single hop, triple hop) at six months after ACL reconstruction. Results: There were 127 patients that met the inclusion criteria, including 63 patients in the NB group (32 males, 31 females) and 64 patients in the control group (26 males, 38 females). There were no significant differences between the NB group and the control group with respect to age (15.7 ± 1.4 vs. 15.5 ± 1.4, p = 0.26), sex (p = 0.29), BMI (23.7 ± 3.6 vs. 23.8 ± 3.6, p = 0.91), or type of graft used (67% patellar tendon autograft, 33% hamstring autograft vs. 70% patellar tendon autograft, 30% hamstring autograft, p = 0.85). Univariate analysis showed a significantly higher deficit at six months in the NB group with respect to fast isokinetic extension strength (17.6% vs. 11.3%, p = 0.008), as well as fast (12.8% vs. 8.3%, p = 0.029) and slow (9.9% vs. 5.5%, p = 0.029) isokinetic flexion strength. There was no difference in slow extension isokinetic strength deficit between the two groups (NB 22.1% vs. control 18.9%, p = 0.246).. With respect to function, there were no differences in deficit for vertical jump (NB 9.3% vs. control 11.3%, p = 0.267), single hop (NB 7.5% vs. control 7.6%, p = 0.970), or triple hop (NB 7.9% vs. control 6.5%, p = 0.375) between the two groups. A higher percentage of patients in the control group met criteria for return to sports at six months. (88.9% vs. 68.3%, p = 0.008). Conclusion: Pediatric and adolescent patients treated with a femoral nerve block for postoperative pain control after ACL reconstruction had significant isokinetic deficits in knee extension (quadriceps) and flexion (hamstring) strength at six months when compared to patients who did not receive a nerve block. No differences in the results of functional testing were observed between the two groups. A significantly higher percentage of patients in the group who did not receive a block were cleared to return to sports at six months following ACL reconstruction.

Objectives: To determine the relationship between lateral tibial slope and probability of early graft failure in patients who have undergone anterior cruciate ligament (ACL) reconstruction. Methods: Fifty-eight patients were initially identified who experienced graft failure following primary ACL reconstruction and were revised between 1989 and 2009. Exclusion criteria were: clinical follow-up of less than four years, graft failure occurring greater than two years from primary surgery, skeletal immaturity, deep infection, lack of availability of preoperative MRI imaging, and history of previous trauma to the proximal tibia. This left 35 cases of early (within 2 years) failure of primary ACL reconstruction. These cases were matched to 35 controls that had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, gender, date of primary surgery, and graft type. Lateral tibial slope was then determined on MRI imaging in blinded fashion. Results: All 35 cases failed within 2 years of primary ACL reconstruction. Mean time to failure in this group was 1 year (range 0.6-1.4 years). Mean follow-up of the matched control group was 6.9 years (range 4.0-13.9 years). Mean lateral tibial slope in the early ACL failure group was found to be 8.4 degrees, which was significantly larger than the control group at 6.5 degrees (p=0.02). The odds ratio for failure considering a 2 degree increase in tibial slope was 1.5 (95% CI 1.02-2.2), and continued to increase to 2.2 (95% CI 1.1-4.6) and 3.3 (95% CI 1.1-10) with 4 degree and 6 degree increases in tibial slope, respectively (Fig 1). No significant association was identified between graft type and primary ACL reconstruction failure. Conclusion: Increased lateral tibial slope is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring lateral tibial slope as part of the preoperative assessment of ACL-injured patients.

Abstract Many tumors are believed to be maintained by a small number of cancer stem–like cells, where cure is thought to require eradication of this cell population. In this study, we investigated the dynamics of acute promyelocytic leukemia (APL) before and during therapy with regard to disease initiation, progression, and therapeutic response. This investigation used a mathematical model of hematopoiesis and a dataset derived from the North American Intergroup Study INT0129. The known phenotypic constraints of APL could be explained by a combination of differentiation blockade of PML–RARα–positive cells and suppression of normal hematopoiesis. All-trans retinoic acid (ATRA) neutralizes the differentiation block and decreases the proliferation rate of leukemic stem cells in vivo. Prolonged ATRA treatment after chemotherapy can cure patients with APL by eliminating the stem-like cell population over the course of approximately one year. To our knowledge, this study offers the first estimate of the average duration of therapy that is required to eliminate stem-like cancer cells from a human tumor, with the potential for the refinement of treatment strategies to better manage human malignancy. Cancer Res; 74(19); 5386–96. ©2014 AACR.

Abstract This resource provides an atlas of common abnormalities that affect the gastrointestinal tract and includes all imaging modalities used within GI radiology, as well as plain radiographs, fluoroscopy, ultrasound, CT, MR, angiography, and nuclear medicine. Focusing solely on adult conditions, it features 13 chapters covering a separate organ within the gastrointestinal system and a final exam chapter reviewing all chapter content. Each organ-focused chapter is subdivided into sections related to diseases or findings of that organ. Large, high-quality images are presented so that they can be reviewed as unknowns. A discussion of the cases is presented as if it were a consultation— with a description of the findings, differential diagnosis, and final diagnosis. A brief discussion of the disease is included. The end of each chapter lists differential diagnoses for the chapter's specific organ. Full-color composite anatomical illustrations show the immediately obvious appearance of common conditions that correlate with major radiologic findings.

ABSTRACT Purpose To present and discuss a case of herniation of subconjunctival orbital fat, a very rare but benign condition. Case Report An 84‐year‐old man presented to the eye clinic for a cataract surgery consultation but also had a secondary complaint about yellow lesions on the bulbar conjunctiva of both eyes. Examination with biomicroscopy revealed protruding orbital masses superotemporally in both eyes, with the right lesion being larger than the left. After thorough testing, these lesions were diagnosed as being subconjuntival herniated orbital fat (HOF), and the patient underwent surgical excision of the lesions. Conclusions In cases of HOF, appropriate and accurate testing is essential, as this condition can mimic several other neoplasms, all of which require specialized treatment strategies. If cosmesis is unacceptable to the patient or the lesion impedes normal ocular function, a subconjunctival excision of the excess fat may be performed with little concern of recurrence. This article discusses a case of HOF, with an explanation of testing and treatment options.

Object Flow diversion has emerged as a promising treatment alternative for cerebral aneurysms. As a new device, treatment-related events and complications are currently being characterized. Methods Data on 100 consecutive procedures with the intention to use flow diversion were prospectively collected and analyzed retrospectively. Results Ninety-five aneurysms were treated in 93 patients during 100 consecutive procedures in which the intention was to treat an intracranial aneurysm with flow diversion. Death occurred in 1% and permanent morbidity in 1%. However, periprocedural technical complications occurred in 35% of the procedures and included proximal device migration in 12%, incomplete device expansion in 9%, catheter-induced vasospasm in 6%, and artery perforation from the wire in 3%. Perioperative clinical events were seen in 28% (thromboembolism and access site complications were the most common, being observed in 6.5% of patients). Worsened extraocular motility was seen in 5.4% and resolved in 4/5 patients. Mean clinical follow-up was 17 months. There were no late clinical or technical issues resulting in permanent deficits, although one patient suffered worsening ataxia. Overall, using very strict angiographic criteria, complete angiographic obliteration was 50% at 6 months and 69% after 1 year. Conclusions Flow diversion for intracranial aneurysms is a safe and effective treatment. Technical and clinical events are common in the perioperative period. Careful perioperative care and proper management of technical and clinical events encountered is key to achieving low morbidity and mortality. Late clinical events can occur but are unlikely to result in permanent complications.

Abstract Previous studies have analyzed patterns of transcription, transcription factor (TF) binding or mapped nucleosome occupancy across the genome. These suggest that the three aspects are genetically connected but the cause and effect relationships are still unknown. For example, physiologic TF binding studies involve many TFs, consequently, it is difficult to assign nucleosome reorganization to the binding site occupancy of any particular TF. Therefore, several aspects remain unclear: does TF binding influence nucleosome (re)organizations locally or impact the chromatin landscape at a more global level; are all or only a fraction of TF binding a result of reorganization in nucleosome occupancy and do all TF binding and associated changes in nucleosome occupancy result in altered gene expression? With these in mind, following characterization of two states (before and after induction of a single TF of choice) we determined: (i) genomic binding sites of the TF, (ii) promoter nucleosome occupancy and (iii) transcriptome profiles. Results demonstrated that promoter-proximal TF binding influenced expression of the target gene when it was coupled to nucleosome repositioning at or close to its binding site in most cases. In contrast, only in few cases change in target gene expression was found when TF binding occurred without local nucleosome reorganization.