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Background: Treatment of failed total ankle arthroplasty (TAA) is challenging. Limited literature is available on options and outcomes of revision arthroplasty despite failure rates ranging from 10% to 23% within 10 years after primary TAA. This study reports the clinical and radiographic outcomes of revision TAA using a fixed-bearing, intramedullary-referencing implant. Methods: A retrospective review was performed of 18 consecutive revision TAA cases between 2008-2015 using an intramedullary-referencing, fixed-bearing, 2-component total ankle system. Demographic and radiographic data were collected preoperatively, immediately postoperatively, and at the most recent follow-up. Functional outcome data were collected immediately postoperatively and at mean follow-up 47.5 months. Results: Eighteen patients underwent revision TAA, with 77.8% (14/18) implant survival. Index revision was performed most commonly for aseptic talar subsidence (55.6%) or implant loosening (tibia, 29.4%; talus, 58.9%). Following revision, 22.2% (4/18) patients required reoperation at a mean 57.3 (39-86) months. Osteolysis of the tibia, talus, and fibula was present preoperatively in 66.7% (12/18), 38.9% (7/18), and 38.9% (7/18) of patients, respectively, with progression of osteolysis in 27.8% (5/18), 11.1% (2/18) and 11.1% (2/18) of patients, respectively. Subsidence of the tibial and talar revision components was observed in 38.9% (7/18) and 55.6% (10/18) of patients, respectively. The median American Orthopaedic Foot & Ankle Society (AOFAS) score was 74.5 (26-100) and Foot Function Index (FFI) score 10.2 (0-50.4). Conclusion: Early results of intramedullary-referencing revision TAA demonstrated good patient-reported outcomes with maintenance of radiographic parameters at mean follow-up of 47.5 months. Aseptic talar subsidence or loosening were the main postoperative causes of reoperation. Revision arthroplasty utilizing an intramedullary-referencing implant was a viable option for the failed TAA. Level of Evidence: Level IV, case series.

Stress fractures of the ankle, relatively rare in the general population, are markedly more common in athletes, especially running and jumping athletes. Athletes who participate in extreme training are at high risk, particularly when compounded with other risk factors such as poor mechanics, footwear, and/or acute changes in regimen. Females, especially elite-level athletes, may be at increased risk to due to the female athlete triad of amenorrhea, inadequate caloric intake, and decreased bone density. Athletes classically present with pain exacerbated by the activity, swelling, and focal tenderness. Diagnosis is often delayed, as initial radiographs are often negative. However, advanced imaging with magnetic resonance imaging (MRI) reveals typical patterns of edema, and, in later stages, fracture lines. Concern for endocrine and/or metabolic abnormalities should prompt further workup, particularly if there is concern for the female athlete triad. Stress fractures at the ankle may be low-risk or high-risk based on their potential for healing. In both scenarios, stress fractures of the fibula, distal tibia, medial malleolus, and talus may be treated initially with rest from activity, and possibly immobilization and/or limited weight-bearing in specific cases. Certain factors may indicate operative management, including lack of response to nonoperative management, progression to sclerosis and/or cystic change at the stress fracture site, or potentially in elite athletes with time-sensitive return-to-play needs and/or high risk of progression. In the future, there may be a role for novel modalities, including teriparatide, extracorporeal shock wave therapy (ESWT), bone stimulators, and orthobiologic agents, but further research is needed.

Category: Other Introduction/Purpose: Cases of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus (COVID-19) first emerged in Wuhan, China, in December 2019. Since then, the virus has spread globally at a rapid pace. The first case in New York City was reported on March 1, 2020, and the World Health Organization (WHO) declared a pandemic on March 11, 2020. New York City rapidly became the epicenter of the pandemic, with hospitals across the city making a number of changes to accommodate the influx of COVID-19 patients. Here, we describe our experience in adapting to the COVID-19 pandemic as a department consisting of 10 foot and ankle fellowship-trained surgeons with up to 28 years of individual experience in an academic orthopedic hospital. Methods: Information was obtained from direct interviews with surgeons in the Foot and Ankle Service and from our institution’s intranet. Additional information was obtained by viewing twice-weekly livestreams from March 27th, 2020 to May 1st, 2020 held by the Surgeon-In-Chief, which detailed hospital-wide policies and initiatives being implemented in the wake of the COVID-19 pandemic. Results: On March 17, 2020, all elective surgeries were suspended at our institution, and a list of essential procedures was established. In-person clinical visits were limited to new patients being evaluated for essential procedures and first postoperative visits for returning patients, with all patients receiving pre-visit and on-site screening for COVID-19. All other new patient and follow-up appointments were conducted via telehealth visits. Much of our main hospital was repurposed to accept transfers of both COVID-negative and COVID-positive patients. A postanesthesia care unit and a floor of 9 operating rooms were repurposed as negative-pressure rooms for the care of critical COVID-positive patients on ventilators. An Orthopedic Triage Center (OTC) was established to relieve the patient load in the emergency departments of other hospitals in the city. Conclusion: By changing the way we delivered foot and ankle care and repurposing the roles of our employees and our institution, we have adapted strategies to continue delivering care to our patients. As we transition toward a ‘new normal,’ our goals are to gradually progress toward normal operations while keeping our patients and employees safe. With these gradual steps, we hope to emerge from this pandemic stronger and ready to adapt to the ever-changing needs of our community.

To improve access to high-quality HIV care in underserved regions of Western Washington (WA) State, we collaborated with the WA State Department of Health (DOH) and community partners to launch four satellite HIV clinics. Here, we describe this innovative clinical care model, present an estimate of costs, and evaluate patient care outcomes, including virologic suppression rates. To accomplish this, we assessed virologic suppression rates 12 months before and 12 months after the satellite clinics opened, comparing people living with HIV (PLWH) who enrolled in the satellite clinics versus all PLWH in the same regions who did not. We also determined virologic suppression rates in 2015 comparing satellite clinic versus non-satellite clinic patients and compared care quality indicators between the satellite clinics and the parent academic clinic. Results demonstrate that the change in virologic suppression rate 12 months before to 12 months after the satellite clinics opened was higher for patients who enrolled in the satellite clinics compared to all those in the same region who did not (18% versus 6%, p < 0.001). Virologic suppression in 2015 was significantly higher for satellite clinic than non-satellite clinic patients at three of four sites. Care quality indicators were met at a high level at the satellite clinics, comparable to the parent academic clinic. Overall, through community partnerships and WA DOH support, the satellite clinic program increased access to best practice HIV care and improved virologic suppression rates in difficult-to-reach areas. This model could be expanded to other regions with inadequate access to HIV practitioners, though financial support is necessary.

Purpose To analyze referral indications, imaging findings and diagnoses in breast sonography in a division of pediatric radiology. Materials and Methods Breast ultrasound examinations of 270 patients were analyzed for referral reasons, imaging findings and final diagnoses (152 females, 118 males). The mean age of the patients was 8.8 years (range, 6 days–18 years). Each breast was examined systematically in two orthogonal probe orientations. Pathological findings were documented on two orthogonal imaging planes. Color Doppler ultrasonography was used additionally. Images and clinical data were reviewed in all cases. Results The most frequent referral reasons in female patients were breast enlargement (104 patients), palpable mass (24 patients) and mastodynia (23 patients). The most frequent diagnoses were normal gland tissue (101 patients), cysts (9 patients), augmented adipose tissue (7 patients) and hemangiomas (7 patients). The most frequent referral reasons in male patients were breast enlargement (106 patients), palpable mass (13 patients) and mastodynia (9 patients). The most frequent diagnoses were gland tissue (79 patients), augmented adipose tissue (24 patients) and cysts (10 patients). Only 2 malignant masses were diagnosed: A Burkitt lymphoma and a relapsed ALL. Conclusion Fear of breast cancer and permanent damage to the breast leads to low-threshold medical consultations and referrals. Sensitive handling is required especially in adolescent patients. Most disorders arise due to the variability of breast development. Ultrasound serves as a means to exclude significant diseases of the breast.

Purpose To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk. Methods Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged. Results Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity. Conclusions Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction. Clinical Relevance Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

Context: Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time. Evidence Acquisition: PubMed articles published from 1974 to January 2012. Results: Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. Conclusions: These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.

Malnutrition in orthopaedic patients, a condition that is overlooked and understudied, has substantial effects on outcomes1-6. Underweight and malnourished elderly patients are at risk of experiencing reduced well-being and autonomy as well as increased mortality as compared with their counterparts of normal weight7. Malnutrition may be simply defined as an imbalance of energy, protein, and nutrients leading to functional and compositional adverse effects on the body8,9. By this definition, as much as 15% of ambulatory and 65% of hospitalized patients are malnourished10. Without adequate nutrition, orthopaedic patients are more susceptible to infections, slower healing rates, and sarcopenia (reduced lean body mass and muscle function)8. Stratifying malnutrition on the basis of etiology (e.g., “starvation-related,” “chronic disease-related,” and “acute injury or illness-related”) facilitates the formation of a more clinically relevant definition11. In starvation, the primary problem is reduced intake, possibly due to socioeconomic factors or secondary to anorexia6. With chronic disease and acute injury, increases in resting energy expenditure and protein requirements due to the inflammatory response contribute to malnourishment7. The new etiology-based approach to the diagnosis of malnutrition …

Simvastatin is a common medication prescribed for hypercholesterolemia that accelerates local bone formation. It is unclear whether simvastatin can accelerate healing at the tendon-bone interface after rotator cuff repair. This study was conducted to investigate whether local and systemic administration of simvastatin increased tendon-bone healing of the rotator cuff as detected by maximum load to failure in a controlled animal-based model. Supraspinatus tendon repair was performed on 120 Sprague-Dawley rats. Sixty rats had a polylactic acid membrane overlying the repair site. Of these, 30 contained simvastatin and 30 did not contain medication. Sixty rats underwent repair without a polylactic acid membrane. Of these, 30 received oral simvastatin (25 mg/kg/d) and 30 received a regular diet. At 4 weeks, 5 rats from each group were killed for histologic analysis. At 8 weeks, 5 rats from each group were killed for histologic analysis and the remaining 20 rats were killed for biomechanical analysis. One rat that received oral simvastatin died of muscle necrosis. Average maximum load to failure was 35.2±6.2 N for those receiving oral simvastatin, 36.8±9.0 N for oral control subjects, 39.5±12.8 N for those receiving local simvastatin, and 39.1±9.3 N for control subjects with a polylactic acid membrane. No statistically significant differences were found between any of the 4 groups ( P >.05). Qualitative histologic findings showed that all groups showed increased collagen formation and organization at 8 weeks compared with 4 weeks, with no differences between the 4 groups at each time point. The use of systemic and local simvastatin offered no benefit over control groups. [ Orthopedics. 2017; 40(2):e288–e292.]

Lateral epicondylitis, or tennis elbow, is the most common cause of elbow pain. This degenerative condition can manifest as an acute process lasting < 3 months or a chronic process often refractory to treatment. Symptom resolution occurs in 70% to 80% of patients within the first year. A "watch-and-wait" approach can be an appropriate treatment option, although physical therapy has been shown to be an effective first-line therapy. Corticosteroids, while providing relief of pain in the acute setting, may be detrimental to recovery in the long term. Platelet-rich plasma injections, although recently well publicized, have not been proven by well-controlled clinical trials to be effective therapy. For patients with symptoms refractory to conservative management, surgical intervention has shown to be a successful treatment modality.

Background: The outcome of rotator cuff repair correlates with tendon healing. Early studies of arthroscopic rotator cuff repair demonstrate lower healing rates than traditional open techniques. Transosseous-equivalent repair techniques (suture bridge) were developed to improve the initial fixation strength. Purpose: To compare the initial in vitro tensile fixation strength of a transosseous-equivalent suture bridge (TOE-SB) rotator cuff repair construct to a traditional transosseous (TO) suture construct. Study Design: Controlled laboratory study. Methods: Identical simulated rotator cuff tears were created on 8 matched pairs of humeri. Each matched pair underwent repair with 4 sutures using either the TOE-SB or TO technique. Initial fixation strength was tested in a custom testing jig. Each shoulder underwent 1000 cycles each of low and then high load testing. Gap displacement was measured at anterior and posterior sites of the repair with digital video tracking of paired reflective markers and recorded at predetermined cycle intervals. Results: There were no statistically significant differences in gap formation at the repair sites under low or high load conditions between TOE-SB and TO techniques. The mean maximal gap formation of the repairs during low load testing in the TOE-SB and TO constructs was 0.93 ± 0.88 mm and 0.55 ± 0.22 mm, respectively ( P = .505). The mean maximal gap formation during high load testing in the TOE-SB and TO constructs was 2.04 ± 1.10 mm and 2.28 ± 1.62 mm, respectively ( P = .517). The most significant increase in gap distance occurred at the transition from low load to high load in both constructs. Most of the incremental displacement occurred within the first 100 cycles for both high and low load testing ( P < .001). Conclusion: The arthroscopic TOE-SB technique is comparable in initial fixation strength to the traditional TO simple suture repair technique. Clinical Relevance: Arthroscopic techniques can achieve initial fixation strength comparable with traditional TO techniques performed without suture anchors.

Background: Radiographic stress testing using both the anterior drawer (AD) and talar tilt (TT) technique is a widely accepted means of assessing ankle instability. The purpose of this study was to investigate the accuracy of plain film radiography in measuring translation of the talus during the AD test and the rotation of the talus during TT stress testing. In addition to determining the true accuracy of radiologic assessment in two planes, our goal was to further define instability in the sagittal, coronal and transverse planes. Methods: Twenty lower extremity specimens were placed in a Telos ankle stress apparatus, and respective lateral and AP radiographs were taken during simulated AD and TT testing. Positional measurements were calculated from the films. Next, a three-dimensional tracking system was used to calculate these displacements. The anterior talofibular ligament and calcaneofibular ligament were sectioned to simulate an unstable ankle, followed by repeat measurement using both methods. Movement calculated using the three dimensional system was compared to that of plain radiographs using a paired t-test. Results: Mean positional changes determined by plain film radiographs were found to be significantly lower than those calculated by the three-dimensional system in both AD and TT tests in the intact and sectioned states ( p< 0.001). Conclusion: Radiographic stress testing assessment of ankle instability appears to be much less accurate than previously believed. Clinical Relevance: Compared to values calculated with the 3D system, radiographic measurements may underestimate the true magnitude of TT and AD changes which could influence clinical decision making.

Internal impingement is a term used to describe the pathologic contact of the undersurface of the rotator cuff with the glenoid. It typically occurs in overhead athletes, particularly throwers. In these athletes, the bones and soft tissues adapt to allow these athletes to have a supraphysiologic range of motion. In many athletes, these changes may lead to symptoms of internal impingement. This article discusses the background, biomechanics, pathophysiology, clinical and radiographic assessment, treatments, and outcomes of this disorder.

Aims Tako-Tsubo cardiomyopathy (TTC) is characterized by rapid regeneration of contractile dysfunction. From recent studies it is known that excessive catecholamine levels due to emotional or physical stress might play a central role. After sympathetic activation, the PIK3/AKT pathway is a key regulator of many cellular responses, including cytoprotective effects. Thus, the purpose of this study was to investigate whether the PIK3/AKT pathway plays a pivotal role in TTC. Methods and results A total of 16 consecutive patients diagnosed with TTC were studied. Left ventricular biopsies were taken during the acute phase and after functional recovery. Specimens were examined by quantitative RT–PCR and western blotting. Representative genes of the PI3K/AKT pathway (PIK3-R1, PTEN, GSK3β, mTOR, PP2A, eIF4E) were compared with left ventricular controls from non-transplanted healthy hearts. PI3K expression was increased during the acute phase and after functional recovery. AKT protein levels were unaltered, but phosphorylation significantly increased during the acute phase. Both PTEN (PI3K antagonist) and PP2 (unspecific phosphatase) were down-regulated. Phosphorylation of the PI3K/AKT downstream target mTOR was increased, while expression of both GSK3 isoforms was decreased. The Bax/Bcl2 ratio was increased in the acute and recovery phases. Conclusion PI3K/AKT signalling is activated in TTC. This activated cell survival cascade might protect cardiomyocytes from cell death and also contribute to rapid regeneration in TTC.

Background: The current clinical standard for the surgical treatment of ankle instability remains the open modified Broström procedure. Modern advents in arthroscopic technology have allowed physicians to perform certain foot and ankle procedures arthroscopically as opposed to traditional open approaches. Methods: Twenty matched lower extremity cadaver specimens were obtained. Steinman pins were inserted into the tibia and talus with 6 sensors affixed to each pin. Specimens were placed in a Telos ankle stress apparatus in an anteroposterior and then lateral position, while a 1.7 N-m load was applied. For each of these tests, movement of the sensors was measured in 3 planes using the Optotrak Computer Navigation System. Changes in position were calculated and compared with the unloaded state. The anteriortalofibular ligament and the calcaneofibular ligament were thereafter sectioned from the fibula. The aforementioned measurements in the loaded and unloaded states were repeated on the specimens. The sectioned ligaments were then repaired using 2 corkscrew anchors. Ten specimens were repaired using a standard open Broström-type repair, while the matched pairs were repaired using an arthroscopic technique. Measurements were repeated and compared using a paired t test. Results: There was a statistically significant difference between the sectioned state and the other 3 states ( P < .05). There were no statistically significant differences between the intact state and either the open or arthroscopic state ( P > .05). There were no significant differences between the open and arthroscopic repairs with respect to translation and total combined motion during the talar tilt test ( P > .05). Statistically significant differences were demonstrated between the 2 methods in 3 specific axes of movement during talar tilt ( P = .04). Conclusion: Biomechanically effective ankle stabilization may be amenable to a minimally invasive approach. Clinical Relevance: A minimally invasive, arthroscopic approach can be considered for treating patients with lateral ankle instability who have failed conservative treatment.

Posterior sternoclavicular dislocations are rare but serious injuries. The proximity of the medial clavicle to the vital structures of the mediastinum warrants caution with management of the injury. Radiographs are the initial imaging test, though computed tomography and magnetic resonance imaging are essential for diagnosis and preoperative planning. This paper presents an efficient diagnostic approach and effective technique of closed reduction of posterior sternoclavicular dislocations with a brief review of open and closed reduction procedures.

Tako-Tsubo cardiomyopathy (TTC) is characterized by the sudden onset of severe left ventricular contractile dysfunction following profound emotional or physical stress. The underlying pathomechanism still remains to be elucidated. In this case we present a, to date, unique case of a female patient suffering from an episode of major depression who shows characteristic features of TTC.

The aim of this study is to evaluate the mechanical properties of a revision anterior cruciate ligament (ACL) reconstruction after redrilling the original tibial bone tunnel through a retained composite screw compared with initial soft tissue graft fixation. A total of 24 porcine tendons were fixed to porcine tibial tunnels with a 10 × 35 mm composite interference screw. Following the pullout test, a revision tunnel was drilled through the first interference screw and a second graft was fixed in the bone tunnel using a larger composite screw (11 × 35 mm). Following insertion of the revision screw, the graft was reloaded as described for the primary reconstruction. Load versus displacement data were recorded for each test. There were no significant differences between the primary and revision reconstruction constructs for yield load (p = 0.62), linear stiffness (p = 0.18), maximum failure load (p = 0.57), and yield displacement (p = 0.46). These results indicate that the mechanical properties of tibial fixation for ACL reconstruction with a composite screw following a revision provide similar fixation compared with initial reconstruction in this model. Revising a failed composite ACL construct by means of overdrilling and reinstrumenting may provide fixation equivalent to the initial reconstruction.

Background: The traditional Brostrom repair and the modified Brostrom-Gould repair are 2 historically reliable procedures used to address lateral ankle instability. The purpose of this study was to evaluate the biomechanical stability conferred by the Brostrom repair as compared to the Brostrom-Gould modification in an unstable cadaveric ankle model. Methods: A total of 10 cadaveric specimens were placed in a Telos ankle stress apparatus in an anterior-posterior position and then in a lateral position, while a 170 N load was applied to simulate anterior drawer (AD) and talar tilt (TT) tests, respectively. In both circumstances, the ankle was held in 15 degrees of plantarflexion, neutral, and 15 degrees of dorsiflexion, while the movement of the sensors was measured using a video motion analysis system. Measurement of the translation between the talus and tibia in the AD test and the angle between the tibia and talus in the TT test were calculated for specimens in the (1) intact, (2) sectioned (division of the ATFL and CFL), (3) Brostrom repair and (4) Gould modification states. Results: When compared to both the repaired states and the intact states, the sectioned state demonstrated increased inversion and translation at all ankle positions during TT and AD testing. Furthermore, no significant differences were found between the intact state and either of the repaired states. Finally, no difference in the biomechanical stability could be identified between the traditional Brostrom repair and the modified Brostrom-Gould procedure. Conclusions: Our findings indicate that there is no significant biomechanical difference in initial ankle stability conferred by augmenting the traditional Brostrom repair with the Gould modification in this time-zero cadaveric model. Clinical Relevance: These data suggest that the additional reinforcement of an ankle’s lateral ligament complex repair of the ankle with the inferior extensor retinaculum may be marginal at the time of surgery.

Ultrasound elastography by acoustic radiation force impulse imaging (ARFI) is used in adults for non invasive measurement of liver stiffness, indicating liver diseases like fibrosis. To establish ARFI in children and adolescents we determined standard values of healthy liver tissue and analysed potentially influencing factors.132 patients between 0 and 17 years old were measured using ARFI. None of them had any liver disease or any other disease that could affect the liver secondarily. All patients had a normal ultrasound scan, a normal BMI and normal liver function tests. The mean value of all ARFI measurements was calculated and potentially influencing factors were analysed.The mean value of all ARFI elastography measurements was 1.16 m/sec (SD ± 0.14 m/sec). Neither age (p = 0.533) nor depth of measurement (p = 0.066) had no significant influence on ARFI values, whereas a significant effect of gender was found with lower ARFI values in females (p = 0.025), however, there was no significant interaction between age groups (before or after puberty) and gender (p = 0.276). There was an interlobar difference with lower values in the right liver lobe compared to the left (p = 0.036) and with a significantly lower variance (p 0.001). Consistend values were measured by different examiners (p = 0.108), however, the inter examiner variance deviated significantly (p 0.001).ARFI elastography is a reliable method to measure liver stiffness in children and adolescents. In relation to studies which analyse liver diseases, the standard value of 1.16 m/sec (± 0.14 m/sec) allows a differentiation of healthy versus pathological liver tissue.

Progressive fibrotic alterations of liver tissue represent a major complication in children with cystic fibrosis. Correct assessment of cystic-fibrosis-associated liver disease (CFLD) in clinical routine is a challenging issue. Sonographic elastography based on acoustic radiation force impulse imaging (ARFI) is a new noninvasive approach for quantitatively assessing in vivo elasticity of biological tissues in many organs.To characterize ARFI elastography as a diagnostic tool to assess alteration of liver tissue elasticity related to cystic fibrosis in children.ARFI elastography and B-mode US imaging were performed in 36 children with cystic fibrosis. The children's clinical history and laboratory parameters were documented. According to the findings on conventional US, children were assigned to distinct groups indicating severity of hepatic tissue alterations. The relationship between US findings and respective elastography values was assessed. Additionally, differences between ARFI elastography values of each US group were statistically tested.Children with sonomorphologic characteristics of fibrotic tissue remodeling presented significantly increased values for tissue elasticity. Children with normal B-mode US or discrete signs of hepatic tissue alterations showed a tendency toward increased tissue stiffness indicating early tissue remodeling.Assessment of children with CFLD by means of ARFI elastography yields adequate results when compared to conventional US. For detection of early stages of liver disease with mild fibrotic reactions of hepatic tissue, ARFI elastography might offer diagnostic advantages over conventional US. Thus, liver stiffness measured by means of elastography might represent a valuable biological parameter for evaluation and follow-up of CFLD.

Chronic lateral epicondylitis is a common painful condition affecting the elbow. Many treatments have been proposed to alleviate the pain. Surgical treatment options include open, arthroscopic, and percutaneous debridement techniques, while nonoperative modalities have traditionally included physical therapy, bracing, and cortisone injections. Platelet-rich plasma injections have recently gained popularity as an additional treatment option, with early reports of success in elite athletes. The largest study of platelet-rich plasma injections for treatment of lateral epicondylitis showed improvement by platelet-rich plasma compared to corticosteroid injections. This article presents a case of a 55-year-old right-hand-dominant woman with bilateral lateral epicondylitis refractory to multiple corticosteroid injections and physical therapy, treated with platelet-rich plasma injection in the right elbow and concomitant arthroscopic extensor carpi radialis brevis tendon release and debridement in the left elbow. At 4-month follow-up, her visual analog scale was 80/100 in the elbow receiving platelet-rich plasma compared to 10/100 on her operative side, and platelet-rich plasma treatment was considered a failure. The patient then underwent arthroscopic debridement of the right elbow for recalcitrant pain. At 1-year follow-up, both elbows were improved after operative treatment (visual analog scale 10/100 right and 0/100 left), consistent with several studies that have reported improvements from arthroscopic extensor carpi radialis brevis debridement as high as 95%. In our experience, arthroscopic extensor carpi radialis brevis debridement is a safe and efficacious method for treating chronic lateral epicondylitis. Further studies are required to define the role of platelet-rich plasma injections in the treatment of this condition.

Aims The Tako-Tsubo cardiomyopathy (TTC) is characterized by a transient contractile dysfunction that has been assigned to excessive catecholamine levels after episodes of severe emotional or physical stress. Several studies have indicated that β-adrenoceptor stimulation is associated with alteration in gene expression of Ca2+-regulatory proteins. Thus, the present study investigated the gene expression of crucial proteins [sarcoplasmic Ca2+ ATPase (SERCA2a), sarcolipin (SLN), phospholamban (PLN), ryanodine receptor (RyR2), and sodium-calcium exchanger (NCX)] involved in the Ca2+-regulating system in TTC. Methods and results In 10 consecutive patients, TTC was diagnosed by coronary angiography, ventriculography, and echocardiography. Endomyocardial biopsies were taken during the phase of severely impaired left ventricular (LV) function and after functional recovery. Non-diseased LV tissue from three donor hearts not used for transplantation served as healthy controls. Expression levels of Ca2+-regulatory proteins were analysed by means of real-time PCR, western blot, and immunohistochemistry. SLN, predominantly expressed in the atrial component, showed a remarkable ventricular expression in TTC patients. Gene expression of SERCA2a was significantly down-regulated. Conversely, PLN/SERCA2a ratio was increased. For PLN, dephosphorylation was documented using western blot and immunostaining of PLN-Ser16 and PLN-Thr17. No changes could be documented for NCX and RyR2. Conclusion In TTC, ventricular expression of SLN and dephosphorylation of PLN potentially result in a reduced SERCA2a activity and its Ca2+ affinity. Thus, the TTC is associated with specific alteration of Ca2+-handling proteins, which might be crucial for contractile dysfunction.

Summary Approximately one million pregnancies are complicated by both malaria and HIV infection in sub-Saharan Africa annually. Both infections have been associated with maternal and infant morbidity and mortality. Intermittent preventive treatment, usually with sulfadoxine-pyrimethamine, has been shown to prevent pregnancy-related malaria and its complications. Several different regimens of antiretroviral therapy are now available to prevent mother-to-child transmission of HIV and/or progression of maternal HIV infection during pregnancy. However, no published studies have yet shown whether standard intermittent preventive treatment and antiretroviral regimens are medically and operationally compatible in pregnancy. We reviewed existing policies regarding prevention and treatment of HIV and malaria in pregnancy, as well as published literature on adverse effects of antiretrovirals and antimalarials commonly used in pregnancy in developing countries, and found that concurrent prescription of sulfadoxine-pyrimethamine, co-trimoxazole (trimethoprim-sulfamethoxazole), and antiretroviral agents including nevirapine and zidovudine per existing protocols for prevention of malaria and vertical HIV transmission may result in adverse drug interactions or overlapping, diagnostically challenging drug toxicities. Insecticide-treated bednets should be provided for HIV-infected pregnant women at risk for malaria. Sulfadoxine-pyrimethamine should be prescribed cautiously in women concurrently receiving daily nevirapine and/or zidovudine, and should be avoided in women on daily co-trimoxazole. Further research is urgently needed to define safe and effective protocols for concurrent management of HIV and malaria in pregnancy, and to define appropriate interventions for different populations subject to differing levels of malaria transmission and antimalarial drug resistance.

In order to separate the interesting physics events from the background without unmanageable deadtime, the ZEUS experiment uses a pipelined trigger and data acquisition system. One of the chief elements of the first level trigger is the Calorimeter First Level Trigger (CFLT). It provides three different categories of information to the Global First Level Trigger (GFLT): numbers of isolated electrons and muons in the calorimeter, patterns of energy deposition derived from local energy sums, and total energy, transverse energy, and missing energy deposited in the calorimeter. The CFLT has to make each step of these calculations, including digitization of the photomultiplier-tube pulse, at a rate of 96 ns in order to keep up with the pipeline. However, in order to reduce the amount of electronics, cables, and crate backplane required, the data are multiplexed in time at several points so that many elements of the system run at faster rates, up to 83 MHz. The CFLT passes trigger information to the GFLT within 2 mu s. >

Brain metastases from prostate adenocarcinoma are rare; spread to brain as the only site of metastasis is even rarer. We present a patient with a large, cystic, solitary intracerebral metastasis from prostate adenocarcinoma. The pertinent literature is reviewed.

Background Many countries in sub-Saharan Africa currently report high prevalences of both human immunodeficiency virus (HIV) and Plasmodium falciparum malaria. The likelihood of HIV-malaria coinfection may affect clinical management of patients. The extent to which standard clinical guidelines address HIV-malaria coinfection is unclear. Methods We reviewed standard World Health Organization and other guidelines for diagnosis and treatment of malaria and/or HIV-related illness. We also searched PubMed (1990 to present) for literature on HIV-malaria interactions and treatment of coinfection. We restricted our review to the situation of the nonpregnant HIV-infected adult. Results We found only 6 articles describing the clinical presentation of HIV-malaria coinfection in adults. We also identified 10 clinical or laboratory syndromes that are shared by malaria and AIDS-related conditions and that might provoke diagnostic confusion. We identified 12 antimalarial medications whose coadministration with antiretrovirals is known or suspected to result in drug-drug interactions or overlapping toxicities. Conclusions Substantial overlap in the clinical and laboratory characteristics of malaria and HIV-related syndromes generates potential difficulties in AIDS staging and in diagnosis and management of patients at risk for coinfection. Significant drug-drug interactions and overlapping drug toxicity profiles further complicate concurrent management of malaria and HIV. Standard clinical guidelines do not reflect the full complexity of the interactions and overlaps between the 2 infections. Clinicians who manage HIV-infected patients in malaria-affected regions should systematically consider malaria when evaluating patients with a broad spectrum of symptoms. Further research is urgently needed to define best practices for prevention, diagnosis, and management of HIV-malaria coinfection in this region.

Parallelversuche mit beschallten und unbeschallten Kaninchen. Sowohl bei der Implantation von kanzerogenen Substanzen und der Transplantation von Hirntumoren, als auch bei der Implantation von Mammatumoren kommt es bei unbeschallten Versuchstieren in kurzer Zeit neben einer raschen Tumorausbreitung zu Erkrankungen der inneren Organe, u. a. zu Leberstauungen, Herz- und Hirnodemen und zum Exitus. Bei den beschallten Versuchstieren Wachstumsstillstand und Eliminierung der implantierten und transplantierten Hirn- und Mammatumoren. Uberleben der Versuchstiere. Makroskopisch keine Erkrankung innerer Organe, kein Hirnodem.

Bei einer Direktbeschallung verletzter Organe, wie Leber, Milz und Niere mit 0,8 Watt cm2, bei einem 3 cm langen und 0,3 mm tiefen Schnitt, kommt es innerhalb von 30–60 s zum sofortigen Stillstand der Parenchymblutungen. Keine Organnaht. Nach Reponierung der Organe, Naht und Beschallung der Bauchdekken. Ergebnis: nach 6 Tagen Eroffnung des Bauchsitus und Vorlegung der beschallten Organe: reizlose hauchdunne Narben an Leber, Milz und Nieren, keine makroskopisch pathologischen Organveranderungen. pp. Heilung der postoperativ beschallten Hautnahte. Beim unbeschallten Versuchstier: pathologische Organveranderungen und Exitus.